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Chronic rhinosinusitis (CRS) is an inflammatory condition of the paranasal sinuses defined by classic symptoms, imaging findings, and/or endoscopic findings. There are a growing number of emerging pharmacologic therapies being evaluated to treat patients with CRS, some of which have gained indication status in the United States. There have not been updated treatment guidelines published in the United States however since 2014. This document is meant to serve as an updated expert consensus document for the pharmacologic management of patients with CRS We review available data focusing on prospective clinical trials on oral and intranasal corticosteroids, nasal irrigation, biologics, antibiotics, and allergy immunotherapy for CRS both with and without nasal polyposis, as well as specific therapies for aspirin exacerbated respiratory disease associated CRS and allergic fungal CRS. There are multiple options to treat CRS, and clinicians should be knowledgeable about the efficacy and risks of these available therapies. Allergists/Immunologists now have various therapies available to treat patients with CRS.

Previous studies examining changes in central sleep apnea (CSA) following adenotonsillectomy (TA) performed for obstructive sleep apnea (OSA) in children have been limited by sample size and analysis of only certain populations. The aim of this study was to determine whether CSA improves following TA and what factors mediate this change.This was a retrospective case series from 1994 to 2020 of children undergoing primary TA for OSA (obstructive apnea-hypopnea index ≥1) with CSA (central apnea index [CAI] ≥1) and preoperative and postoperative polysomnograms within 12 months of TA. Polysomnograms were analyzed for improvement in CSA, defined as: 1) if preoperative CAI5, a postoperative CAI5; or 2) if preoperative CAI5, a postoperative CAI1.One hundred twenty-three patients were included. Median age was 5.5 years (interquartile range, 2.9-8.4). Most patients were overweight/obese (58.5%). Nineteen (15.4%) had a syndromic condition. Preoperative CAI was ≥5 in 21 (17.1%) patients. CAI significantly decreased following TA (preoperative 2.1, postoperative 0.4; P .001). Thirty-two (26.0%) patients had CSA postoperatively. Improvement in the microarousal index and older age were significantly associated with improvement in CSA.TA led to resolution of CSA in most children with OSA. Improvement in the microarousal index was associated with improvement in CAI, suggesting that preoperative central apneas may be postarousal and thus resolve following TA.4 Laryngoscope, 132:478-484, 2022.

I. Executive summary BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document. Methods ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary. Results ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided. Conclusion This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Background: The objective of this study was to analyze and report our experience with using polysomnography (PSG) during the early consolidation phase of mandibular distraction osteogenesis (MDO) in patients with Pierre Robin Sequence and associated tongue-based airway obstruction with management decisions informed by the results. The secondary objective was to determine whether pre-operative PSG can predict which patients will have persistent obstructive sleep apnea (OSA) and require additional distraction. Methods: A single-surgeon, retrospective review was performed of all patients who underwent MDO for treatment of tongue-based airway obstruction over an 11-year period. Pre-operative and post-distraction 16-channel overnight bedside PSG was performed on all patients and scored according to the AASM Scoring Manual. Patients who demonstrated persistent OSA underwent further distraction and were reevaluated by PSG after final distraction length was achieved. Results: Pre-operative and post-distraction PSG was obtained and available for analysis in 37 patients. Apnea-Hypopnea Index (AHI) improved from 45.85 ± 34.41 to 9.73 ± 10.85 ( P 2. There was no significant difference in patient characteristics or pre-operative symptoms between the 2 groups. Conclusions: PSG can be performed at the bedside at the end of the distraction phase of MDO to assess for residual airway obstruction and inform the need for further distraction. Pre-operative PSG measures can help predict the need for further distraction and aid in operative planning and distractor placement.

This comprehensive practice parameter for allergic rhinitis (AR) and nonallergic rhinitis (NAR) provides updated guidance on diagnosis, assessment, selection of monotherapy and combination pharmacologic options, and allergen immunotherapy for AR. Newer information about local AR is reviewed. Cough is emphasized as a common symptom in both AR and NAR. Food allergy testing is not recommended in the routine evaluation of rhinitis. Intranasal corticosteroids (INCS) remain the preferred monotherapy for persistent AR, but additional studies support the additive benefit of combination treatment with INCS and intranasal antihistamines in both AR and NAR. Either intranasal antihistamines or INCS may be offered as first-line monotherapy for NAR. Montelukast should only be used for AR if there has been an inadequate response or intolerance to alternative therapies. Depot parenteral corticosteroids are not recommended for treatment of AR due to potential risks. While intranasal decongestants generally should be limited to short-term use to prevent rebound congestion, in limited circumstances, patients receiving regimens that include an INCS may be offered, in addition, an intranasal decongestant for up to 4 weeks. Neither acupuncture nor herbal products have adequate studies to support their use for AR. Oral decongestants should be avoided during the first trimester of pregnancy. Recommendations for use of subcutaneous and sublingual tablet allergen immunotherapy in AR are provided. Algorithms based on a combination of evidence and expert opinion are provided to guide in the selection of pharmacologic options for intermittent and persistent AR and NAR.

Performance of tracheotomy is a potential necessary step in the patient with coronavirus disease 19 (COVID-19) and prolonged mechanical ventilation. Due to viral aerosolization, tracheotomy carries a high risk of transmission of COVID-19 to the health care team performing the procedure. We share our institution's surgical safety checklist for performing tracheotomy in patients with COVID-19, including key modifications intended to mitigate risk to the surgical team.

The Clinical Assessment Score-15 (CAS-15) has been validated as an office-based assessment for pediatric sleep-disordered breathing in otherwise healthy children. Our objective was to determine the generalizability of the CAS-15 in a multi-institutional fashion.Five hundred and thirty children from 13 sites with suspected sleep-disordered breathing were recruited, and the investigators completed the CAS-15. Based on decisions made in the course of clinical care, investigators recommended overnight polysomnography, observation, medical therapy, and/or surgery. Two hundred and forty-seven subjects had a follow-up CAS-15.Mean age was 5.1 (2.6) years; 54.2% were male; 39.1% were white; and 37.0% were African American. Initial mean (standard deviation [SD]) CAS-15 was 37.3 (12.7), n = 508. Spearman correlation between the initial CAS-15 and the initial apnea-hypopnea index (AHI) was 0.41 (95% confidence interval [CI], 0.29, 0.51), n = 212, P .001. A receiver-operating characteristic curve predicting positive polysomnography (AHI 2) had an area under the curve of 0.71 (95% CI, 0.63, 0.80). A score ≥ 32 had a sensitivity of 69.0% (95% CI, 61.7, 75.5), a specificity of 63.4% (95% CI, 47.9, 76.6), a positive predictive value of 88.7% (95% CI, 82.1, 93.1), and a negative predictive value of 32.9% (95% CI, 23.5, 44.0) in predicting positive polysomnography. Among children who underwent surgery, the mean change (SD) score was 30.5 (12.6), n = 201, t = 36.85, P .001, effect size = 3.1.This study establishes the generalizability of the CAS-15 as a useful office tool for the evaluation of pediatric sleep-disordered breathing.2B Laryngoscope, 130:2256-2262, 2020.

STUDY OBJECTIVES: Adenotonsillectomy (AT) is the treatment of choice for obstructive sleep apnea (OSA) in children with adenotonsillar hypertrophy. Severe OSA, identified by the apnea-hypopnea index (AHI), is a risk factor for surgical complications and AHI thresholds are used by surgeons to decide elective postoperative hospital admissions. The objective of this study was to identify the prevalence of surgical complications of AT in children with severe OSA and determine their association with specific parameters of polysomnography (PSG). METHODS: Retrospective evaluation of respiratory and nonrespiratory complications in children undergoing AT for severe OSA was performed. Events were then compared to several individual PSG indices. PSG indices included classic parameters such as AHI, and obstructive apnea indexes (OAI) as well as gas exchange parameters including the oxygen desaturation index (ODI), lowest oxyhemoglobin saturation (lowest SpO(2)), peak end-tidal CO(2) (peak ETCO(2)), the percentage of the total sleep time (%TST) with ETCO(2) > 50 mmHg (%TST ETCO(2) > 50 mmHg) and oxygen saturation < 90% (%TST O(2) < 90%). RESULTS: A total of 158 children were identified with severe OSA. Major respiratory complications occurred in 21.5% and were only associated with the ODI (P = .014), lowest SpO(2) (P = .001) and %TST O(2) < 90% (P < .001). Minor respiratory complications occurred in 19.6% and these were not associated with any PSG parameters. Major nonrespiratory complications occurred in 4.4% and also were not associated with any PSG parameters; however, minor nonrespiratory complications occurring in 37.3%, and were associated with %TST O(2) < 90% (P < 0.001). CONCLUSIONS: PSG measures of gas exchange are strongly associated with postoperative complications of AT and are better suited for postoperative planning than classic indices such as AHI. CITATION: Molero-Ramirez H, Tamae Kakazu M, Baroody F, Bhattacharjee R. Polysomnography parameters assessing gas exchange best predict postoperative respiratory complications following adenotonsillectomy in children with severe OSA. J Clin Sleep Med. 2019;15(9):1251–1259.

Background The COVID-19 pandemic forced surgeons to reconsider concepts of “elective” surgery. Perceptions regarding the time-sensitivity and medical necessity of a procedure have taken on greater significance during the pandemic. The evolving ethical and clinical environment requires reappraisal of perioperative factors such as personal protective equipment conservation; limiting the risk of exposure to COVID-19 for patients, families, and health care workers; preservation of hospital beds and intensive care unit resources; and minimizing COVID-19 related perioperative risk to patients. Study design A scaffold for the complex decision-making required for prioritization of Medically Necessary, Time Sensitive (MeNTS) surgeries was developed for adult patients by colleagues at The University of Chicagoi. Although adult MeNTS scoring can be applied across adult surgical specialties, some variables were irrelevant in a pediatric population. Pediatric manifestations of chronic diseases and congenital anomalies were not accounted for. In order to account for the unique challenges children face, we modified the adult MeNTS system for use across pediatric subspecialties. Results This Pediatric MeNTS (pMeNTS) scoring system was applied to 101 cases both performed and deferred between March 23rd and April 19th, 2020, at The University of Chicago Comer Children’s Hospital. The pMeNTS scores provides a safe, equitable, transparent, and ethical strategy to prioritize children’s surgical procedures. Conclusions This process is adaptable to individual institutions, and we project it will be useful during the acute phase of the pandemic (maximal limitations) as well as the anticipated recovery phase., Graphical abstract

The development of biologics targeting various aspects of type 2 inflammation for the treatment of chronic rhinosinusitis with nasal polyps (CRSwNP) will provide clinicians with powerful tools to help treat these patients. However, other therapies are also available, and positioning of biologics in a management algorithm will require comparative trials. In November 2019, the National Institute of Allergy and Infectious Diseases convened a workshop to consider potential future trial designs. Workshop participants represented a wide spectrum of clinical specialties, including otolaryngology, allergy, and pulmonary medicine, as well as expertise in CRSwNP pathophysiology and in trial methodology and statistics. The workshop discussed the current state of knowledge in CRSwNP and considered the advantages and disadvantages of various clinical trial or observational study designs and various clinical outcomes. The output from this workshop, which is presented in this report, will hopefully provide investigators with adequate information and ideas to design future studies and answer critical clinical questions. It will also help clinicians understand the current state of the management of CRSwNP and its gaps and be more able to interpret the new information to come.

Objective:To investigate airway morphology changes in patients with Pierre Robin sequence (PRS) pre–/post–mandibular distraction osteogenesis (MDO) and to compare morphologic changes to age-matched controls.Design:Retrospective case–control study.Setting:Urban, academic, tertiary medical center.Patients, Participants:Fifteen patients with PRS after MDO to relieve upper airway obstruction (UAO) (2008-2018); age-matched controls for post-MDO patients.Interventions:Mandibular distraction osteogenesis, curvilinear internal mandibular distractors.Main Outcome Measures:(1) Physiologic improvement after MDO (apnea–hypopnea index; minimum oxygen saturation); (2) airway size (volume, surface area, length, mean/minimum cross-sectional area), shape (lateral:anterior–posterior ratio, cross-sectional area ratios, uniformity, sphericity), and changes with MDO; and (3) post-MDO airway size, shape versus age-matched controls.Results:Airway size increased after MDO (volume, P = .01; surface area, P = .02; length, P = .01), as did cross-sectional area (mean, P = .02; minimum, P = .02; minimum retropalatal, P = .05, mid-retroglossal, P = .02). Post-MDO PRS airways were larger than controls (volume, P < .01; surface area, P < .01; length, P < .01, cross-sectional area, P = .03). Airway shape remained nonuniform and flat post-MDO; control airways were round. Two syndromic patients required repeat MDO and had subphysiologic post-MDO airway cross-sectional area. Post-MDO PRS patients with supraphysiologic cross-sectional area along the entire airway had no UAO recurrence.Conclusions:In this small, heterogenous patient sample, MDO increases airway size, may preferentially affect the retropalatal airway, and often results in supraphysiologic airway dimensions. These retropalatal changes may be important in relieving severe UAO in patients with PRS. Generalizability of our results is limited by small cohort size and patient heterogeneity.

Sinonasal disease in its multiple forms affects billions of people worldwide. Although physicians train to precisely diagnose a patient and then treat appropriately, the sheer number of people afflicted with sinonasal disease precludes this approach. We argue that patients should first be treated with an intranasal corticosteroid for 2 weeks. Based on their perceived response, they should be triaged. Those who respond well can be instructed on how to continue to manage their disease. Those who do not would be referred to allergists or otolaryngologists for diagnosis and treatment. We believe this pragmatic approach is safe, provided first-line physicians, physician assistants, and nurse practitioners recognize some warning symptoms and signs of serious, but infrequently occurring, sinonasal diseases that would not lend themselves to this proposed approach.

BACKGROUND: Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR). METHODS: Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus. RESULTS: The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR. CONCLUSION: This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.

Several new, promising, targeted therapies for nasal polyposis are being tested in large-scale clinical trials. These agents target pathways thought to be involved in the disease, including IgE, IL-5, IL-4/IL-13, and others. Designing these trials poses significant challenges: who and when to enroll is not completely clear, optimal dosing is not known, outcome measures are insufficiently robust, there are no validated biomarkers, trial regimens may not comport with how clinicians might use these drugs once approved, and cost-benefit ratios have not been assessed. Thus, there is a need to consider such questions, as trials of these novel treatments continue and these biologics become available. Despite these uncertainties about trial design, there remains a great deal of excitement in the field as we approach the dawn of a new era of therapeutic options for nasal polyposis. In this rostrum, we enumerate these issues and call for a conference that will allow stakeholders in the field to confront them as we enter this new era of opportunity to advance the treatment of nasal polyposis.

To determine the impact of a video intervention administered at the time of the universal newborn hearing screen on caregiver knowledge of infant cognitive and language development in low socioeconomic status English-speaking parents.A parallel-group, single-blind randomized clinical trial was conducted from April to August 2016. Eligible participants were at least 18 years, delivered a singleton neonate, English speaking, and designated as low socioeconomic status based on household income and level of education. A total of 112 patients, 54 treatment and 58 control, completed the study and were included in the analysis. The Baby Survey of Parent/Provider Expectations and Knowledge, a validated 24-item questionnaire assessing child development knowledge, was the primary study outcome. The survey was conducted at baseline, 1 day after intervention, and 4-6 weeks later. A one-way, repeated measures analysis of variance (ANOVA) was employed to evaluate for differences in the three time points.The average age of participants was 25.6 years and 85% identified as African-American. There was no significant difference in scores prior to and following the intervention for the control group (N = 58, F = 1.67, p = 0.19); however, a significant difference in scores was found in the treatment group (N = 54, F = 7.95, p 0.001). Post-hoc analysis showed a significant improvement in scores 1 day after intervention, but no difference 4-6 weeks later.Educational video intervention for low socioeconomic mothers at the time of the universal newborn hearing screen can positively increase knowledge related to hearing and language development in the short term.Pilot Study of Novel Postpartum Educational Video Intervention NCT02267265 https://clinicaltrials.gov/ct2/show/NCT02267265.

Background Traditional methods of staging chronic rhinosinusitis (CRS) through imaging do not differentiate between degrees of partial mucosal sinus inflammation, thus limiting their utility as imaging biomarkers. We hypothesized that software-aided, quantitative measurement of sinus inflammation would generate a metric of disease burden that would correlate with clinical parameters in patients with suspected sinus disease. Methods Adults with rhinologic complaints undergoing computed tomography imaging were recruited at an urban, academic, tertiary care center (n = 45 with Lund-Mackay [LM] scores ≥4). Three-dimensional (3D) volumetric image analysis was performed using a semiautomated method to obtain a “Chicago-modified Lund-Mackay” (Chicago MLM) score, which provides a continuous scale to quantify extent of opacification. Linear regression was used to test the association of the Chicago MLM score with concurrent symptoms (Total Nasal Symptom Score [TNSS]) and disease-specific quality of life, based on the Sinonasal Outcome Test-22 (SNOT-22). Results Chicago MLM scores were significantly associated with both symptoms (p = 0.037) and disease-specific quality of life (p = 0.007). Inflammation in the ethmoid and sphenoid sinuses appeared to influence these associations. These findings were even more robust when analysis was limited to patients with more severe disease (LM >6). Conclusion The quantitative measurement of sinus inflammation by computer-aided 3D analysis correlates modestly with both symptoms and disease-specific quality of life. Posterior sinuses appear to have the greatest impact on these findings, potentially providing an anatomic target for clinicians to base therapy. The Chicago MLM score is a promising imaging biomarker for clinical and research use.

Heterotopic gastrointestinal cyst of the oral cavity is a rare congenital lesion that may arise from ectopic undifferentiated endodermal cells. Imaging, particularly MRI, is useful for surgical planning. On MRI, the cysts typically demonstrate high signal on T2-weighted sequences and variable signal on T1-weighted sequences, which can resemble other conditions, such as dermoids. On histology, the appearance of these lesions can be variable, and may include stratified squamous, simple and ciliated columnar, as well as foveolar and intestinal-type epithelia, often surrounding by smooth muscle. Complete surgical excision is the treatment of choice.

Rhinosinusitis is defined as inflammation of the nose and paranasal sinuses. Pediatric patients with rhinosinusitis are often thought to have other common conditions. The diagnosis is based on physical symptoms as well as objective signs seen on either nasal endoscopy or computerized tomography (CT) scan. Rhinosinusitis can be further categorized based on the duration of signs and symptoms, into acute, recurrent acute, and chronic rhinosinusitis. Parents report that children with rhinosinusitis have a negative impact on the quality of life of their children as compared to other common chronic diseases, such as asthma and juvenile rheumatoid arthritis.

Rhinosinusitis is a commonly encountered problem in both pediatric and otorhinolaryngologic practices with a recent increase in the diagnosis of acute rhinosinusitis (ARS) and chronic rhinosinusitis (CRS) in both adult and pediatric patients. This is likely a consequence of an improved understanding of the etiology, pathophysiology, and microbiology of the disease. This chapter overviews the medical treatment of the disease with special focus on the evidence supporting corticosteroid therapy.

Gastroesophageal reflux disease is a common occurrence in the pediatric age group and tends to improve with age. A relationship between pediatric chronic rhinosinusitis and gastroesophageal reflux has been speculated, though a true cause-and-effect relationship has yet to be solidified. Available evidence linking gastroesophageal reflux disease to pediatric rhinosinusitis will be reviewed in this chapter. Similarly, the impact of reflux therapy on the progress of rhinosinusitis in children will be summarized. Based on the current literature, there appears to be some correlation between the two entities, but the evidence does not seem to justify routine empiric treatment of reflux in children with chronic rhinosinusitis in the absence of overt gastroesophageal reflux disease symptoms.

Background Little is known about the use of allergy and asthma medications in older adults. This study aimed to assess the prevalence of use of these medications in older adults and evaluate predictors of their use. Methods Cross-sectional study using data from the National Social Life, Health, and Aging Project (NSHAP), a nationally representative sample of community-dwelling, U.S. adults 57 to 85 years (n = 2976) collected in 2005–2006. We determined prevalence of medication use and used logistic regression to evaluate sociodemographic and health factors associated with their use. Results Overall prevalence of allergy medication usage was 8.4% (most commonly antihistamines), and prevalence of asthma medication usage was 8.0% (most commonly bronchodilators). Allergy medication use was significantly associated with history of asthma (odds ratio [OR] 2.37; 95% confidence interval [CI], 1.52 to 3.69), chronic obstructive pulmonary disease (COPD) (OR 2.35; 95% CI, 1.58 to 3.51), or nasal surgery (OR 1.97; 95% CI, 1.00 to 3.86). Older age was associated with decreased allergy medication use (per decade, OR 0.80; 95% CI, 0.66 to 0.98). Although increased education was associated with increased overall allergy medication use, it was associated with decreased use of allergy medications generally contraindicated in the elderly. In contrast, the only significant predictors of asthma medication use were history of asthma (OR 19.66; 95% CI, 3.18 to 121.70) or COPD (OR 4.25; 95% CI, 0.88 to 20.44). Conclusion Allergy and asthma medication use is prevalent among older adults and driven mostly by history of asthma or COPD. Additional sociodemographic factors predict allergy (but not asthma) medication use. Further studies are needed to evaluate efficacy of these drugs in the elderly.

Background Allergic rhinitis is a common disorder that leads to a negative impact on quality of life. Multiple options are available for treatment of the symptoms, but preventing the reaction should be an effective strategy. Objective We tested a nasal spray that contained microcrystalline cellulose designed to limit airborne allergens from penetrating the nasal mucosa (nasal blocker) and, therefore, prevent the initiation of the allergic reaction. Methods We performed a randomized, double-blind, placebo-controlled, two-way crossover clinical trial with 20 subjects who had a history of seasonal grass and/or ragweed allergy symptoms. Each subject underwent two separate nasal challenges with antigen (provocations) after application of the investigational product or placebo to both nostrils. The allergen was delivered into one nostril at a time and was administered at 2-hour intervals (identified as challenge 1 and challenge 2). We assessed peak nasal inspiratory flow and total nasal symptoms as well as the number of sneezes recorded at both 15-minute and 1-hour intervals after challenge 1 and, later, challenge 2. After a washout period, the subjects returned to undergo the alternate therapy. Results There was a significant overall decrease in peak nasal inspiratory flow after both treatments (investigational product, p = 0.005; placebo, p = 0.001), but, when the average of the change from baseline in peak nasal inspiratory flow was compared with the baseline, the results showed no significant differences between the groups (p = 0.31). Similar results were obtained for total nasal symptoms. Conclusion The investigational product did not prove to be significantly better than placebo in treating seasonal allergic rhinitis symptoms.

Nonallergic rhinitis is a common disease that affects many Americans. It is characterized by nasal symptoms of congestion and rhinorrhea without evidence of allergic sensitization. The pathophysiology of the disease has not been studied extensively. In the following article, the author concentrates on summarizing the available information related to cellular inflammation and neurogenic mechanisms in patients with nonallergic rhinitis. The author also explores nasal reactivity to various stimuli in these patients.

Background The body of knowledge regarding rhinosinusitis(RS) continues to expand, with rapid growth in number of publications, yet substantial variability in the quality of those presentations. In an effort to both consolidate and critically appraise this information, rhinologic experts from around the world have produced the International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR:RS). Methods Evidence-based reviews with recommendations(EBRRs) were developed for scores of topics, using previously reported methodology. Where existing evidence was insufficient for an EBRR, an evidence-based review (EBR)was produced. The sections were then synthesized and the entire manuscript was then reviewed by all authors for consensus. Results The resulting ICAR:RS document addresses multiple topics in RS, including acute RS (ARS), chronic RS (CRS)with and without nasal polyps (CRSwNP and CRSsNP), recurrent acute RS (RARS), acute exacerbation of CRS (AECRS), and pediatric RS. Conclusion As a critical review of the RS literature, ICAR:RS provides a thorough review of pathophysiology and evidence-based recommendations for medical and surgical treatment. It also demonstrates the significant gaps in our understanding of the pathophysiology and optimal management of RS. Too often the foundation upon which these recommendations are based is comprised of lower level evidence. It is our hope that this summary of the evidence in RS will point out where additional research efforts may be directed.

Three-dimensional computed tomography has been used in both preoperative planning of mandibular distraction osteogenesis and in the evaluation of postoperative resolution of tongue-based airway obstruction. The authors present a case report using software to predict postdistraction airway volume during virtual surgical planning (VSP) of mandibular distraction osteogenesis in a 7 year old. The predicted increase in airway volume derived from VSP was 33.57% (1716 mm(3) preoperatively to 2292 mm(3) postvirtual distraction). Based on the three-dimensional computed tomography, the actual airway volume increased to 2211 mm(3) postoperatively, a 28.85% increase.The implications of this advancing technology are far-reaching. An illustrative case is presented herein to demonstrate the efficacy of the airway prediction and its limitations. The authors believe that, with continued investigation, this novel approach may be a standard feature of all VSP sessions for the treatment of tongue-based airway obstruction.

Purpose of review Pediatric tracheotomy is a common procedure. Given the risk of morbidity and mortality associated with long-term placement, it is imperative that decannulation is considered once the indication for tracheotomy placement is corrected or resolved. In this article, we discuss the critical steps necessary for the assessment of readiness for decannulation, and we review the recent literature that supports several methods of evaluation that may be incorporated into a protocol for decannulation. Recent findings Recent literature related to the topics of pediatric tracheotomy and decannulation is limited to case series and retrospective reviews, though relatively large patient populations are encompassed within individual studies. The data presented support the use of routine predecannulation endoscopic exam, as well as progressive daytime and overnight inpatient capping trials to ensure adequate airway patency, capped polysomnography for patients with underlying obstructive sleep apnea and/or dynamic airway disease, and 24-h inpatient observation after decannulation to determine tolerance and detect early failures requiring tracheotomy replacement. Summary Although the assessment of readiness for decannulation may be challenging, several evaluative steps are recommended to ensure safe and effective decannulation in pediatric patients. Apparent variation in decannulation outcomes by underlying cause may herald the development of indication-specific decannulation protocols in the future.

Objective To develop a clinical consensus statement on the use of sinus ostial dilation (SOD) of the paranasal sinuses. Methods An expert panel of otolaryngologists was assembled to represent general otolaryngology and relevant subspecialty societies. The target population is adults 18 years or older with chronic or recurrent rhinosinusitis (with or without nasal polyps, with or without prior sinus surgery) for whom SOD is being recommended, defined as endoscopic use of a balloon device to enlarge or open the outflow tracts of the maxillary, frontal, or sphenoid sinuses, as a standalone procedure or with endoscopic surgery. A modified Delphi method was used to distill expert opinion into clinical statements that met a standardized definition of consensus. Results After 3 iterative Delphi method surveys, 13 statements met the standardized definition of consensus while 45 statements did not. The clinical statements were grouped into 3 categories for presentation and discussion: (1) patient criteria, (2) perioperative considerations, and (3) outcomes. Strong consensus was obtained for not performing SOD in patients without sinonasal symptoms or positive findings on computed tomography (CT) in patients with symptoms only of headache or sleep apnea without criteria for sinusitis. In addition, strong consensus was met that CT scan of the sinuses was necessary before performing SOD and that surgeons need to understand and abide by regulations set forth by the US Food and Drug Administration if they choose to reuse/reprocess devices. Conclusion Expert panel consensus may provide helpful information for the otolaryngologist considering the use of SOD for the management of patients with a diagnosis of rhinosinusitis. This panel reached consensus on a number of statements that defined the use of SOD as inappropriate in the management of a variety of symptoms or diseases in the absence of underlying sinusitis. When patients meet the definition of chronic sinusitis as confirmed by CT scan, SOD of the sinuses can be indicated and/or effective in certain scenarios. Additional consensus statements regarding proper setting and safeguards for performing the procedure are described.

BACKGROUND The authors investigated the accuracy of virtual surgical planning in predicting airway volume changes after mandibular distraction in patients with Pierre Robin sequence and associated tongue-based airway obstruction. METHODS The authors completed a single-institution retrospective review of patients for whom virtual surgical planning was used during mandibular distraction osteogenesis for treatment of tongue-based airway obstruction. Preoperative airway volume, virtual surgical planning-predicted airway volume, and postoperative airway volume were calculated from three-dimensional computed tomographic scans using industry software. A blinded institutional radiologist also calculated pre- and post-operative airway volumes. Pre- and post-operative polysomnography was used to titrate the endpoint of mandibular lengthening. RESULTS Eleven patients were included in the study. Mean apnea-hypopnea index (5.42 ± 4.53 versus 44.96 ± 20.57; p < 0.001) and mean nadir oxygen saturation (70.3 ± 9.72 percent versus 82.9 ± 9.62 percent; p = 0.003) improved with mandibular distraction. There was moderate correlation between predicted and actual mandibular distraction lengths (R = 0.65; p = 0.003). There was a strong correlation between predicted and industry-calculated actual post-distraction airway volume (R = 0.99; p < 0.001). There was no significant correlation between actual mandibular distraction length and industry-calculated actual post-distraction airway volume for the entire cohort (R = 0.05; p = 0.49), but correlation approached significance by institutional calculations. No significant correlation existed between industry and institutional-calculated percentage change in post-distraction airway volume (R = 0.06; p = 0.57). CONCLUSIONS Predictive airway volume calculation may be an effective adjunct to determine anatomic endpoint of mandibular distraction but small sample size, operator and software variability, and patient airway morphology may confound firm conclusions. Further studies are warranted.

Background Patients presenting with unilateral sinus symptoms or nasal polyps raise concerns about sinister pathology. Yet despite the relatively common occurrence of this presentation, and its potential severity, an organized diagnostic approach to unilateral sinus disease (USD) has never been defined. The purpose of this work was to propose a diagnostic algorithm for managing patients with USD based on prior experience. Methods We performed a retrospective review of the medical records of all patients with USD who underwent surgical intervention and had pathological specimens during a 15-year period at an urban academic center. Nasal endoscopy and computed tomography (CT) scan findings, demographic characteristics, presenting symptoms, medical histories, and previous treatments were analyzed. Results A total of 191 patients met the inclusion criteria, 153 of whom were initially diagnosed at our center. Among the latter group, 51 (33%) presented with a nasal mass or polyp observed by endoscopy. Inverted papilloma was present in 16% of those cases, and malignant tumors comprised 14%. In contrast, of patients without an obvious nasal polyp (n = 102), 2% had inverted papilloma and 3% had malignancies. Overall, chronic rhinosinusitis was the most common diagnosis both in patients with polyps (67%) and those without nasal polyps (69%). Conclusion Although USD is most likely to represent chronic inflammation, there exists a fair likelihood of finding malignant pathology, particularly in cases where patients have a unilateral polyp. Based on this review, we propose a strategy for the management of new presentations of USD.

Background The Lund-Mackay (LM) staging system for chronic rhinosinusitis (CRS) does not correlate with clinical parameters, likely due to its coarse scale. We developed a “Modified Lund Mackay” (MLM) system, which uses a three-dimensional (3D), computerized method to quantify the volume of mucosal inflammation in the sinuses, and sought to determine whether the MLM would correlate with symptoms and disease-specific quality of life. Methods We obtained Total Nasal Symptom Score (TNSS) and 22-item Sino-Nasal Outcome Test (SNOT-22) data from 55 adult subjects immediately prior to sinus imaging. The volume of each sinus occupied by mucosal inflammation was measured using MATLAB algorithms created using customized, image analysis software after manual outlining of each sinus. Linear regression was used to model the relationship between the MLM and the SNOT-22 and TNSS. Correlation between the LM and MLM was tested using Spearman's rank correlation coefficient. Results Adjusting for age, gender, and smoking, a higher symptom burden was associated with increased sinonasal inflammation as captured by the MLM (β = 0.453, p < 0.013). As expected due to the differences in scales, the LM and MLM scores were significantly different (p < 0.011). No association between MLM and SNOT-22 scores was found. Conclusion The MLM is one of the first imaging-based scoring systems that correlates with sinonasal symptoms. Further development of this custom software, including full automation and validation in larger samples, may yield a biomarker with great utility for both treatment of patients and outcomes assessment in clinical trials.

The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) has published a supplement to this issue featuring the new Clinical Practice Guideline: Allergic Rhinitis. To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 14 recommendations developed address the evaluation of patients with allergic rhinitis, including performing and interpretation of diagnostic testing and assessment and documentation of chronic conditions and comorbidities. It will then focus on the recommendations to guide the evaluation and treatment of patients with allergic rhinitis, to determine the most appropriate interventions to improve symptoms and quality of life for patients with allergic rhinitis.

Background The management of pediatric chronic rhinosinusitis (PCRS) is evolving. Objective To assess current practice patterns of members of the American Rhinologic Society (ARS) in managing PCRS. Methods A 27-item Web-based survey on treatment of PCRS was electronically distributed to the ARS membership. Results The survey was completed by 67 members, 40% of whom had completed a rhinology fellowship. The most frequently used medical therapies as part of initial treatment for PCRS were nasal saline solution irrigation, (90%), topical nasal steroids (93%), oral antibiotics (52%), and oral steroids (20%). For initial surgical therapy, 90% performed adenoidectomy; in addition, 31% also performed sinus lavage, 17% performed balloon catheter dilation (BCD), and 17% performed endoscopic sinus surgery (ESS). Sixty percent performed adenoidectomy before obtaining computed tomography imaging. When initial surgical treatment failed, 85% performed traditional ESS. In patients with pansinusitis, 50% of the respondents performed frontal sinusotomy and 70% performed sphenoidotomy. BCD was not frequently used; overall, 66% never or rarely used it, 20% sometimes used it, 12% usually used it, and 3% always or almost always used BCD. Conclusions Most aspects of PCRS management among ARS members were aligned with published consensus statements. Adenoidectomy was almost always included as part of first-line surgical treatment but was also combined with adjunctive surgical procedures with moderate frequency. ESS was performed by a minority of rhinologists as a primary procedure for medically refractory PCRS but was favored when previous surgery failed. BCD was uncommonly used in PCRS.

Background Microbes and allergens can stimulate the nasal mucosa, potentially leading to the development of acute bacterial rhinosinusitis (ABRS). This study was designed to determine if allergen exposure alters the sinonasal microbiome. Methods We performed a parallel observational study of healthy adults with seasonal allergic rhinitis (SAR; grass or tree, n = 20) or nonallergic subjects (n = 19). Microbiota specimens were obtained by endoscopy from the middle meatus and vestibule before and during the relevant season and were analyzed by terminal restriction fragment length polymorphism analysis. Differences in bacterial microbiota were assessed by standard ecological measures of bacterial diversity. Quality of life and symptom scores were recorded, and nasal lavages for eosinophils were performed. Results SAR subjects had increased nasal symptoms in season, impaired disease-specific quality of life, and increased nasal eosinophils, compared with no changes in nonallergic subjects. During the season, SAR subjects had a significantly greater variety of organisms in the middle meatus compared with nonallergic subjects (p < 0.036) and increased bacterial diversity (Shannon index, p < 0.013). We found a significant positive correlation between bacterial diversity in the middle meatus during the season and the nasal lavage eosinophil count of SAR subjects. There were no significant changes in the nasal vestibule (p > 0.05, all comparisons). Conclusion The interaction of allergy and microbiota may affect the sinonasal physiology, with broad implications for several airway diseases. Characterization of the specific organisms involved using next-generation sequencing may clarify the relationship between allergic inflammation and ABRS. This finding may help explain why allergic inflammation predisposes to ABRS.

Background Systemic corticosteroids are the most effective anti-inflammatory drugs used for controlling chronic rhinosinusitis (CRS) symptoms. The potential mechanisms for their beneficial effects include increasing the number and function of T regulatory cells (Tregs), as reported in the local tissue post–intranasal steroid treatment. We investigated the effect of systemic corticosteroids on peripheral blood (PB) Tregs in subjects with CRS. Methods Twenty CRS subjects and 19 controls were recruited. PB mononuclear cells (PBMCs) were isolated from CRS subjects before and after systemic corticosteroid administration in the course of clinical treatment. Control subjects received no treatment and were studied at one visit. Nasal symptoms were recorded. CD4+CD25+Foxp3+ cells (Tregs) were analyzed by flow cytometry. Messenger RNA (mRNA) levels for interferon γ (IFN-γ), interleukin 4 (IL-4), IL-10, IL-13, IL-17A, transforming growth factor β1 (TGF-β1), forkhead box P3 (FoxP3), and GATA-binding factor 3 (GATA-3) were measured in PBMCs using real-time polymerase chain reaction (PCR). Results CRS subjects reported improved nasal symptoms (p = 0.005) and significantly reduced PB Tregs after treatment with corticosteroids (p = 0.042). The transcript levels of IL-4 and GATA-3 were significantly higher in the CRS subjects at their first visit when compared to controls (p = 0.019 and p = 0.05, respectively). Corticosteroid treatment lowered the transcript levels of immunoregulatory transcription factors [FoxP3 (p = 0.048) and GATA-3 (p = 0.012)] and IFN-γ (p = 0.036) in PB. Conclusion In contrast to prior work in local nasal tissue, our study reports reduced PB Tregs and decreased T helper 1 (TH1) and TH2 function after treatment with systemic corticosteroids. These data indicate that corticosteroid effects on Tregs in CRS are complex involving local signals in the tissue that are distinct from those in circulating cells.

Background We investigated whether nebulization of budesonide via a NasoNeb® device would treat perennial allergic rhinitis. Methods We performed a parallel, randomized, double-blind, placebo-controlled, pilot study in subjects (n = 40) with perennial allergic rhinitis. After recording baseline symptoms, subjects were randomized to budesonide respules (0.25 mg) or an equivalent placebo for 26 days. Nasal peak inspiratory flow (NPIF) and nasal symptoms (graded on a 0–3 scale) were recorded by the subjects twice daily. Rhinoconjunctivitis quality of life (RQOL) as well as nasal volume, measured by acoustic rhinometry, was obtained at baseline, after 2 weeks, and at the end of treatment. Results The average change from baseline in symptoms over the treatment period was greater for the group on budesonide (−3.33) compared to placebo (−1.98) (p = 0.45). When the average change from baseline over the treatment period was compared between the groups, budesonide resulted in higher NPIF (36.4 L/min) than placebo (18.7 L/min), p = 0.094. QOL improved in both groups compared to baseline with no significant difference between the groups. Although acoustic rhinometry indicated a larger volume in the group treated with budesonide on the last trial visit, the differences between the groups were not significant when accounting for the baseline values. Conclusion Compared to placebo, administration of nebulized budesonide in subjects with perennial allergic rhinitis resulted in improvements in symptoms and objective measures of nasal congestion which approached but did not achieve statistical significance. A higher dose of active agent, a less effective placebo and a larger number of subjects might have improved statistical significance.

Background Sleep-disordered breathing in general and obstructive sleep apnea in particular are commonly encountered conditions in allergy practice. Physiologically, nasal (or nasopharyngeal) obstruction from rhinitis, nasal polyposis, or adenotonsillar hypertrophy are credible contributors to snoring and nocturnal respiratory obstructive events. Nevertheless, existing practice parameters largely relegate the role of the allergist to adjunctive treatment in cases of continuous positive airway pressure intolerance. Objectives To survey active American Academy of Allergy, Asthma & Immunology members regarding their perceptions and practices concerning sleep-disordered breathing in adult and pediatric patients with rhinitis, and to review the medical literature concerning this connection to identify therapeutic implications and research gaps. Methods Members of the Work Group on Rhinitis and Sleep-disordered Breathing composed and distributed a Web-based clinically oriented survey to active American Academy of Allergy, Asthma & Immunology members in mid-2015. The group, in addition, conducted an English-language literature review using PubMed and other sources. Results Survey results were returned by 339 of 4881 active members (7%). More than two-third of respondents routinely asked about sleep problems, believed that sleep-disordered breathing was a problem for at least a "substantial minority" (10%-30%) of their adult patients, and believed that medical therapy for upper airway inflammatory conditions could potentially help ameliorate sleep-related complaints. Literature review supported the connection between high-grade nasal congestion/adenotonsillar hypertrophy and obstructive sleep apnea, and at least in the case of pediatric patients, supported the use of anti-inflammatory medication in the initial management of obstructive sleep apnea of mild-to-moderate severity. Conclusions Clinical allergy practice and the medical literature support a proactive role for allergists in the diagnosis and management of sleep-disordered breathing.

Chronic rhinosinusitis (CRS) is difficult to define, partly because the disease recognized by clinicians is both heterogeneous and the endpoint of different pathophysiologic, genetic, and environmental interactions. For this article, we define CRS as symptoms lasting more than 3 months combined with an imaging study showing inflammation in the sinuses. This article comments on some factors that are believed to influence the expression of CRS. These factors include anatomic abnormalities, immotile cilia, age, allergic sensitization, immune deficiency, dental infections, gastrointestinal reflux, smoking, biofilm, and the microbiome. Other factors are discussed in other sections. The article concludes with an overview of treatment. In brief, nasal steroids and large volume nasal irrigations are the first line of treatment for this inflammatory disease. Antibiotics are used when infections are thought to contribute. Oral steroids are frequently used in severe disease. Endoscopy and sinus computed tomography scans are used when surgery is contemplated.

Background The pathogenesis of chronic rhinosinusitis (CRS) has not been fully elucidated. Increased inflammatory cell infiltration and decreased numbers and/or impaired function of T regulatory cells (Tregs) have been reported. This study aimed to determine the role of Tregs in CRS in peripheral blood (PB) and sinus tissue. Methods Sinus tissue was obtained from 16 CRS subjects and 5 controls. PB from additional 16 CRS subjects and total 20 controls was obtained. Immunohistochemical analysis (CD3+, CD4+, CD8+, and Treg [CD4+-FoxP3+ and CD25+-FoxP3+] cells) of sinus tissue was performed. Percentage of PB Tregs (CD4+-CD25+-FoxP3+ cells) was analyzed by flow cytometry. Spontaneous and phytohemagglutin (PHA)-induce lease of cytokines (IL-6, IL-4, IL-10, interferon gamma, transforming growth factor [TGF] beta1, and TNF-alpha) from PB mononuclear cells (PBMCs) was determined. Results PB flow cytometric analysis revealed a lower percentage of Tregs in subjects with CRS compared with healthy controls (p = 0.0003). Although no differences in the PB Treg counts were observed between the CRS subjects with nasal polyposis (CRSwNP) and without nasal polyposis (CRSsNP), immunohistochemical analysis performed on sinus tissue revealed a higher proportion of Tregs in CRSwNP subjects compared with CRSsNP (p < 0.05). Additionally, we failed to detect any Tregs from control sphenoid sinus tissue. Lower levels regulatory cytokines (IL-10 and TGF-β1) and higher levels of proinflammatory cytokines (TNF-α and IL-6) were found from PBMCs from CRS subjects compared with controls (p < 0.05). Conclusion Our findings suggest that CRS subjects exhibit a decreased percentage of PB Tregs compared with normal controls. PBMCs from CRS subjects show a more proinflammatory and less regulatory phenotype.

The European Position Paper on Rhinosinusitis and Nasal Polyps 2012 is the update of similar evidence based position papers published in 2005 and 2007. The document contains chapters on definitions and classification, we now also proposed definitions for difficult to treat rhinosinusitis, control of disease and better definitions for rhinosinusitis in children. More emphasis is placed on the diagnosis and treatment of acute rhinosinusitis. Throughout the document the terms chronic rhinosinusitis without nasal polyps (CRSsNP) and chronic rhinosinusitis with nasal polyps (CRSwNP) are used to further point out differences in pathophysiology and treatment of these two entities. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. Last but not least all available evidence for management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is analyzed and presented and management schemes based on the evidence are proposed. This executive summary for otorhinolaryngologists focuses on the most important changes and issues for otorhinolaryngologists. The full document can be downloaded for free on the website of this journal: http://www.rhinologyjournal.com.

The nose is an integral part of the upper airway and the first contact of the body with inspired air. It is located in close proximity to several related airway structures that include the ears, paranasal sinuses, and eyes. It is also closely linked to the lower airway. Multiple lines of evidence support a close interaction and influence of the nose on these contiguous and distant organs via neural reflexes and systemic inflammatory processes. These interactions are reviewed in light of existing evidence.

Evidence suggests IgE may play a role in chronic rhinosinusitis (CRS). We sought to determine if treatment with a monoclonal antibody against IgE (omalizumab) is effective in reducing CRS inflammation. We performed a randomized, double blind, placebo controlled clinical trial in subjects with CRS despite treatment (including surgery). Subjects were randomized to receive omalizumab or placebo for 6 months. The primary outcome was quantitative measurement of sinus inflammation on imaging. Secondary outcome measures included quality of life, symptoms, and cellular inflammation, nasal airflow (NPIF) and olfactory testing (UPSIT). Subjects on omalizumab showed reduced inflammation on imaging after treatment, whereas those on placebo showed no change. The net difference, however, was not different between treatments. Treatment with omalizumab was associated with improvement in the Sino-Nasal Outcome Test (SNOT-20) at 3, 5, and 6 months compared to baseline with no significant changes in the control group. Remaining measures showed no significant differences across treatments. We conclude that IgE plays, at most, a small role in the mucosal inflammation of CRS and the symptoms. Placebo controlled, blinded studies with larger enrollment are needed to determine the clinical significance of any potential change.

Guidelines for the treatment of patients with allergic rhinitis (AR) recommend intranasal corticosteroids as first-line therapy. In clinical trials, however, only 50% of patients obtain excellent symptom control.To evaluate the effectiveness of montelukast add-on therapy in patients with perennial AR (PAR) who have incomplete relief of symptoms after 2 weeks of treatment with intranasal fluticasone propionate.We performed a 4-week parallel, randomized, double-blind, placebo-controlled trial. One hundred two patients with a history of PAR and a positive skin test reaction to perennial allergens were recruited. They completed the Rhinitis Quality of Life Questionnaire (RQLQ) and were given intranasal fluticasone propionate, 200 microg daily. They were asked to complete symptom diary cards twice daily. After 2 weeks of treatment, patients with a mean total nasal symptom score of at least 4 during the past week (n = 54) were randomized to receive either montelukast (n = 28) or placebo (n = 26) in addition to the continued use of fluticasone propionate. At weeks 3 and 4, the RQLQ was completed again and symptom diary cards were collected.Compared with baseline, there were significant improvements in almost all domains of the RQLQ while taking fluticasone propionate (P.001). A similar trend was observed for nasal symptom scores. After randomization to receive montelukast or placebo, there were no significant differences in RQLQ measures or nasal symptom scores between the groups during the 2 weeks of combination therapy.The addition of montelukast to an intranasal corticosteroid for the treatment of PAR with residual symptoms is no more effective than is placebo.

Background Allergic rhinitis (AR) is commonly associated with olfactory loss, although the mechanism is not well studied. This study was designed to determine the effect of mometasone furoate (MF) on olfactory loss in seasonal AR (SAR) and study its effect on inflammation in the olfactory region. Methods We performed a randomized, double-blind, placebo-controlled, parallel clinical trial in 17 patients with SAR who had symptoms of impaired olfaction. Subjects received MF or placebo for 2 weeks during their allergy season. Before and after treatment, we measured nasal peak inspiratory flow (NPIF), chemosensory quality of life, and objective olfactory function (the University of Pennsylvania Smell Identification Test). Additionally, nasal cytology samples were obtained from each visit, and a unilateral endoscopic biopsy specimen of the olfactory epithelium was obtained at the end of the study and scored for inflammation. Results Treatment with MF was associated with improved nasal symptoms (p < 0.015), NPIF (p < 0.04), reduced nasal inflammation (p < 0.05), and chemosensory-specific quality of life (p < 0.03). Histological analysis of the olfactory region reveals fewer eosinophils in the MF group when compared with placebo (p < 0.012). We found no improvement in objective olfactory function (p > 0.05). Conclusion The use of MF in SAR is associated with reduced eosinophilic inflammation in the olfactory region and improved symptoms of AR. The presence of eosinophils in the olfactory area in SAR may indicate a direct, deleterious effect of inflammation on olfactory epithelium in this disease. In this study we show that inflammation in SAR can affect the olfactory cleft, implicating a direct role for allergic inflammation in smell loss. Treatment with intranasal steroids is associated with decreased inflammation in the olfactory region in humans. This treatment is also associated with improved olfactory quality of life.

Objectives: A national survey of pediatric cochlear implantation (PCI) audiologists was conducted with three aims: (1) to determine if PCI audiologists perceive within their clinical practice a negative effect of low socioeconomic status (SES) on postimplant speech and language outcomes; (2) to understand their perceptions of the underlying factors leading to outcome disparities; and (3) to elicit suggestions for improving outcomes in disadvantaged populations. We hypothesized that audiologists would perceive reduced speech and language outcomes within their lower SES patient population, and that this noted disparity would be related to parental adherence (compliance) and access to habilitation. Design: A survey containing 22 quantitative and open-ended questions was electronically mailed to a data base of 234 PCI audiologists. Forty-four percent (N = 103 of 234) responded to the survey, with the majority (98 of 103) answering all questions. Quantitative responses were analyzed using the Stata 9 statistical package with significance at p < 0.05. Qualitative responses were analyzed using standardized codebook and content analysis. Transcripts were read and coded for the main ideas expressed in each response. The codes were then analyzed for patterns and organized into subthemes that were then grouped into themes. Results: Seventy-eight percent (N = 76 of 98) of respondents perceived an effect of SES on postimplant speech and language outcomes. Qualitative responses uniformly demonstrated audiologists' perception that lower SES patient populations were more likely to experience reduced speech and language outcomes. Two major themes emerged in audiologists' explanations of SES-related disparities: internal factors of parental influence (i.e., parental self-efficacy, adherence, and habilitation carryover), and external factors (i.e., inadequate therapy and lack of available resources). Three primary suggestions were offered for reducing the disparity: improvement in cochlear implant services (92%), increased emphasis on parental education and intervention (87%), and the development of stricter candidacy requirements (15%). Conclusions: This study offers evidence to show that PCI audiologists note an SES-related disparity in the field of PCI. Respondents suggest the need for a broad and culturally sensitive effort to both increase access to qualified healthcare professionals and develop approaches that will aid parents in the at-home habilitation process.

Summary Objective Dysphagia secondary to “tight” distal esophageal wraps are a well-known complication of Nissen fundoplication (NF). However, the literature makes no mention of distal esophageal foreign bodies (DEFB) appearing after NF. This study was undertaken to determine the occurrence of asymptomatic DEFB in children post-fundoplication. Methods A retrospective review and case series of radiographic images of children who underwent NF between 2001 and 2004. Images reviewed include chest and abdominal radiographs, esophagrams, and oropharyngeal motility studies. Main outcome DEFB on radiology report and image. Results Two hundred and thirty-three children (135 males and 98 females) underwent NF at the ages of 15 days to 19.5 years. Two thousand and seven radiographs were reviewed. Five FBs (2.15%) were noted. Four of the five FBs (80%, overall incidence 1.72%) were present in the distal esophagus. Three required rigid esophagoscopy (one marble and one with multiple foreign bodies (FBs) for removal. One who had a distal FB seen on barium swallow ‘spontaneously passed’ during esophagoscopy. Conclusion DEFB in children status post-NF is unusual with an incidence 1.72% of our patients. Our review might be underestimating the incidence as translucent foreign bodies may have been missed. DEFB are surprising due to the fact that most of these children are neurologically impaired and gastrostomy-tube fed. The children's NPO status may also result in these DEFB remaining asymptomatic until being ‘incidentally’ found on radiographic imaging. Thus, NF may predispose to obstruction when a foreign body (FB) is ingested; but because of the population involved, this remains a fairly unusual entity. However, the presence of a DEFB in this population may necessitate prompt endoscopic retrieval as the likelihood of spontaneous passage is less.

Objectives: Nasal continuous positive airway pressure (CPAP) treatment causes nasal symptoms that are believed to result from the drying effects of the air on the nasal mucosa, and these symptoms affect compliance with therapy. We hypothesized that the increased air pressure on the nasal mucosa caused by positive pressure from CPAP would decrease the ability of the nose to warm and humidify inspired air, explaining these symptoms. Methods: We performed a 4-way crossover trial using CPAP pressures of −5, 0, +5, and +10 cm H2O in 10 subjects. The ability to warm and humidify inspired air was determined by measurement of the temperature of a fixed volume of cold, dry air entering and exiting the nostril and calculation of the amount of water supplied to the airstream by the nose. Results: The water content of air was unaffected at the pressures studied. Conclusions: The pressure of delivered CPAP does not affect the ability of the nose to warm and humidify inspired air.

To test whether intranasal ciprofloxacin/dexamethasone or dexamethasone alone affects the course of acute bacterial rhinosinusitis in mice.We performed a randomized, double-blind, parallel, placebo-controlled study in mice.Three groups of 10 C57Bl/6 mice were infected with Streptococcus pneumoniae, and then 1 day later randomized to treatment with placebo, ciprofloxacin plus dexamethasone, or dexamethasone. The mice were killed 3 or 10 days after treatment was begun.The placebo-treated mice became infected and developed an inflammatory cell infiltration in their sinuses. None of the treatments significantly affected the course of the illness.The lack of topical, intranasal efficacy of ciprofloxacin and dexamethasone could be attributed to subpotent dosage, rapid nasal clearance, or inability of the drops to reach the site of infection. Treatment with dexamethasone neither improved nor worsened the bacterial infection.