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Objective: Confocal laser endomicroscopy (CLE) is an optical imaging technique that allows in vivo, real-time, microscope-like assessment of superficial lesions. Although there is substantial data on CLE use in the upper GI tract, there is limited information regarding its application in the nasal cavity and paranasal sinuses. This study aims to assess the feasibility and diagnostic metrics of CLE in the nasal cavity and paranasal sinuses regarding differentiation between healthy/benign and malignant tissue. These structures show, however, a wider variety of frequent and concomitant benign and malignant pathologies, which could pose an increased challenge for optical biopsy by CLE., Methods: We performed CLE on a case series of six patients with various findings in the nose (three chronic rhinosinusitis, adenocarcinoma, meningoenzephalozele, esthesionneuroblastoma). Forty-two sequences (3792 images) from various structures in the nasal cavity and/or paranasal sinuses were acquired. Biopsies were taken at corresponding locations and analyzed in hematoxylin and eosin staining as a standard of reference. Three independent examiners blinded to the histopathology assessed the sequences., Results: Healthy and inflamed mucosa could be distinguished from malignant lesions with an accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of 84.1%, 85.4%, 83.1%, 72.5%, and 92.1%, respectively, with a substantial agreement between raters (Fleiss κ = 0.62)., Conclusion: This technique shows, despite its limitations, potential as an adjunctive imaging technique during sinus surgery; however, the creation of a scoring system based on reproducible and defined characteristics in a larger more diverse population should be the focus of further research to improve its diagnostic value and clinical utility., Level of Evidence: NA Laryngoscope, 134:4217-4224, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Pediatric chronic rhinosinusitis (PCRS) differs from adult chronic rhinosinusitis (CRS) in several aspects. The confrontation with the environment takes place in the growing sinus system, and the immune system is also developing. The inflammatory mechanisms differ to some extent from those of adult CRS patients. The adenoid vegetations play an important role, particularly during the first 6 years of life. Other pathogenetic aspects are important (e.g., asthma, gastroesophageal reflux disease, immunodeficiency). Genetically determined systemic diseases such as cystic fibrosis cause specific challenges in diagnostics and treatment already in childhood. Consistent conservative therapy is often successful, but surgical procedures that have been proven to be effective and associated with few complications are also increasingly used., (© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Chronic rhinosinusitis (CRS) is a significant public health problem. Bacterial colonization and impaired mucociliary clearance play a significant role in the inflammatory process. Several inflammatory pathways and host defense elements are altered in CRS, which may contribute to observed differences in the microbiome. To date, researching CRS has been difficult due to limited access to the studied tissue and a lack of available biomarkers. Ongoing scientific research is increasingly based on simple and objective analytical methods, including sensors, detection with PCR, and sequencing. Future research on microbiota and human factors should also include genomics, transcriptomics, and metabolomics approaches. This report analyzes the changes that occur in the paranasal sinuses of people with acute and chronic rhinosinusitis, the composition of the microbiota, the human genetic markers that may shed light on the predisposition to CRS, and the advantages and disadvantages of classical and molecular diagnostic methods, as well as addressing the difficulties of sinusitis treatment.

Purpose of Review: The purpose of this review is to summarize the recent literature relating to viral, fungal and bacterial infections and their interactions within the sinonasal tract in the past 18 months., Recent Findings: Coronavirus disease 2019 (COVID-19)-associated olfactory dysfunction (OD) is variant dependent. Magnetic resonance imaging studies have found greater olfactory cleft opacification and higher olfactory bulb volume in post-COVID-19 OD. Olfactory training remains the mainstay of treatment, while platelet-rich plasma injections and ultramicronized palmitoylethanolamide and luteolin combination oral supplementation have shown early promise.Consensus statements on paranasal sinus fungal balls and acute invasive fungal sinusitis have been released.Studies on the nasal microbiome have reported Staphylococcus and Corynebacterium as the most abundant genera, with higher levels of Staphylococcus and Corynebacterium being found in patients with chronic rhinosinusitis (CRS) and healthy individuals respectively. However, there is conflicting evidence on the significance of biodiversity of the nasal microbiome found in CRS versus healthy patients., Summary: While the peak of the COVID-19 pandemic is behind us, its sequelae continue to pose treatment challenges. Further studies in OD have implications in managing the condition, beyond those afflicted post-COVID-19 infection. Similarly, more research is needed in studying the nasal microbiome and its implications in the development and treatment of CRS., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Commonly used endoscopic grading scales, such as the nasal polyp scale, inadequately describe the degree of polyposis found postoperatively in the paranasal sinus cavities. The purpose of this study was to create a novel grading system that more accurately characterizes polyp recurrence in postoperative sinus cavities, the Postoperative Polyp Scale (POPS)., Methods: A modified Delphi method was utilized to establish the POPS using consensus opinion among 13 general otolaryngologists, rhinologists, and allergists. Postoperative endoscopy videos from 50 patients with chronic rhinosinusitis with nasal polyps were reviewed by 7 fellowship-trained rhinologists and scored according to the POPS. Videos were rated again 1 month later by the same reviewers, and scores were assessed for test-retest and inter-rater reliability., Results: Overall inter-rater reliability for the first and second reviews of the 52 videos was Kf = 0.49 (95% CI 0.42-0.57) and Kf = 0.50 (95% CI 0.42-0.57) for the POPS. Intra-rater reliability showed near-perfect test-retest reliability for the POPS with Kf = 0.80 (95% CI 0.76-0.84)., Conclusion: The POPS is an easy-to-use, reliable, and novel objective endoscopic grading scale that more accurately describes polyp recurrence in the postoperative state which will be useful in the future for measuring the efficacy of various medical and surgical interventions., Level of Evidence: 5 Laryngoscope, 133:2885-2890, 2023., (© 2023 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Chronic rhinosinusitis (CRS) and asthma commonly co-occur. No studies have leveraged large samples needed to formally address whether preexisting CRS is associated with new onset asthma over time., Methods: We evaluated whether prevalent CRS [identified in two ways: validated text algorithm applied to sinus computerized tomography (CT) scan or two diagnoses] was associated with new onset adult asthma in the following year. We used electronic health record data from Geisinger from 2008 to 2019. For each year we removed persons with any evidence of asthma through the end of the year, then identified those with new diagnosis of asthma in the following year. Complementary log-log regression was used to adjust for confounding variables (e.g., sociodemographic, contact with the health system, comorbidities), and hazard ratios (HRs) and 95% confidence intervals (CI) were calculated., Results: A total of 35,441 persons were diagnosed with new onset asthma and were compared to 890,956 persons who did not develop asthma. Persons with new onset asthma tended to be female (69.6%) and younger (mean [SD] age 45.9 [17.0] years). Both CRS definitions were associated (HR, 95% CI) with new onset asthma, with 2.21 (1.93, 2.54) and 1.48 (1.38, 1.59) for CRS based on sinus CT scan and two diagnoses, respectively. New onset asthma was uncommonly observed in persons with a history of sinus surgery., Conclusion: Prevalent CRS identified with two complementary approaches was associated with a diagnosis of new onset asthma in the following year. The findings may have clinical implications for the prevention of asthma., (© 2023 The Authors. Allergy published by European Academy of Allergy and Clinical Immunology and John Wiley & Sons Ltd.)

Objectives: The main aim of this study is to analyze the possible differences between clinical, demographic or genetic characteristics, in Cystic Fibrosis (CF) patients with chronic rhinosinusitis (CRS) with different phenotype. The secondary objective is to describe the possible benefit of surgery with Centripetal Endoscopic Sinus Surgery (CESS)., Methods: The study includes 56 who performed CT scan of the paranasal sinuses. They were divided in 3 group according to phenotype: CRS without Nasal Polyps (NP); CRS with NP; CRS complicated with Mucocele. The clinical symptoms, age, gender, genotype, microbial colonization and pulmonary disease stage were collected and analyzed to assess possible statistically significant differences. Regarding the 7 patients who performed CESS surgery, the number of hospitalizations, intravenous (iv) antibiotic courses, respiratory exacerbations, the FEV1, the Lund-Mackay Score (LMS) and the SNOT 22 were evaluated before and 1 year after surgery., Results: No statistically significant differences regarding clinical symptoms between the 3 groups were identified (p > 0.05). Furthermore, there were no differences in age, gender, genotype, microbial colonization and pulmonary disease stage (p > 0.05). Regarding the patients who performed CESS, no significative difference in FEV1 progression was found. A reduction in hospitalization, pulmonary exacerbation and in the number of iv antibiotic courses resulted statistically significant different (p = 0.004; <0.001 and <0.001 respectively). A significant improvement in SNOT-22 and LMS (p < 0.001) was obtained., Conclusion: Radiological monitoring of the rhinosinus disease is necessary regardless of the clinical expression of the disease. The presence of CRS with NP complicated by mucocele is frequent and independent of the patient's age and clinical manifestations. An extensive surgical approach could represent the gold standard for patients with CF in consideration of the potential important advantages to perform a total toilet of all the sinuses and nasal cavities and at the same time eliminating a potential microbiological reservoir., Competing Interests: Declaration of competing interest There is no conflict of interest to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Paranasal sinus fungus balls (PSFB) are a common form of surgically treatable, noninvasive mycosis. To date, no guidelines have standardized PSFB treatment or management of difficult cases (eg, immunocompromised or fragile patients). The clinical consensus statement presented herein aims to provide a comprehensive management guide to PSFB based on current evidence., Methods: A multidisciplinary, international panel of 19 specialists judged statements in 3 rounds of a modified Delphi method survey. Statements encompassed the following PSFB management issues: definition, diagnostic workup; treatment indications and modalities; and follow-up. Otolaryngologists, maxillofacial surgeons, infectious disease specialists, and transplant physicians were considered the target audience., Results: Among the 23 statements, 7 reached strong consensus and 16 reached consensus. Consensus was reached on the definition, diagnosis, and treatment modalities for PSFB. Postoperative follow-up modalities and scenarios with bacterial superinfection were the most debated issues., Conclusion: Until further data are available, these points provide a framework for the management of PSFB. Moreover, PSFB should be considered a noninvasive mycosis that is not necessarily symptomatic or related to odontogenic conditions. Although diagnosis may be incidental, endoscopy and single imaging (computed tomography or magnetic resonance imaging, with distinctive features) are required for diagnosis, whereas contrast medium would allow for differential diagnosis. Although treatment of PSFB should be considered mandatory before sinus augmentation and is recommended for symptomatic patients, immunosuppressed patients, or patients with planned immunosuppression, watchful waiting could be considered for asymptomatic patients with chronic rhinosinusitis who are provided with appropriate advice and assessment., (© 2022 The Authors. International Forum of Allergy & Rhinology published by Wiley Periodicals LLC on behalf of American Academy of Otolaryngic Allergy and American Rhinologic Society.)

Invasive fungal sinusitis (IFS) is more common in immunosuppressed patients but can also occur in immunocompetent hosts. While the non-invasive type of fungal sinusitis has usually a good prognosis, IFS is a potentially lethal condition.We report the case of a woman in her 60s presenting an isolated fungal infection by Aspergillus fumigatus of the right sphenoid sinus, causing extensive bone erosion of its walls and complicated by severe meningoencephalitis. She was healthy without any immunosuppressive conditions. Methods of diagnosis, multidisciplinary management, follow-up and outcomes are documented.Early-stage diagnosis of sphenoid sinus pathologies is often delayed because patients are usually asymptomatic. IFS of the sphenoid is more aggressive than other paranasal sinus and carries significant mortality. Early diagnosis and aggressive and multidisciplinary treatment are crucial to reduce sequels and improve patient's survival., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To critically review the literature on nasal nitric oxide (nNO) and its current clinical and research applicability in the diagnosis and treatment of different sinonasal inflammatory diseases, including acute bacterial rhinosinusitis (ABRS), allergic rhinitis (AR), and chronic rhinosinusitis (CRS)., Methods: A search of the PubMed database was conducted to include articles on nNO and sinonasal diseases from January 2003 to January 2020. All article titles and abstracts were reviewed to assess their relevance to nNO and ABRS, AR, or CRS. After selection of the manuscripts, full-text reviews were performed to synthesize current understandings of nNO and its applications to the various sinonasal inflammatory diseases., Results: A total of 79 relevant studies from an initial 559 articles were identified using our focused search and review criteria. nNO has been consistently shown to be decreased in ABRS and CRS, especially in cases with nasal polyps. While AR is associated with elevations in nNO, nNO levels have also been found to be lower in AR cases with higher symptom severity. The obstruction of the paranasal sinuses is speculated to be an important variable in the relationship between nNO and the sinonasal diseases. Treatment of these diseases appears to affect nNO through the reduction of inflammatory disease burden and also mitigation of sinus obstruction., Conclusion: nNO has been of increasing interest to researchers and clinicians over the last decade. The most compelling data for nNO as a clinical tool involve CRS. nNO can be used as a marker of ostiomeatal complex patency. Variations in measurement techniques and technology continue to impede standardized interpretation and implementation of nNO as a biomarker for sinonasal inflammatory diseases.

Purpose: To investigate the different clinical manifestations in Egyptian patients with orbital complications of rhinosinusitis (RS) according to the pathology within the paranasal sinuses., Methods: The medical records of patients presented with chronic RS between August 2018 and December 2020 were retrospectively reviewed., Results: This study included 64 patients: 28 patients with subperiosteal abscess (SPA), 10 with allergic fungal RS, 6 with isolated fungal RS, 6 with invasive fungal RS, and 14 with mucocele. The most common manifestation was proptosis, limitation of ocular motility, periorbital swelling, and pain. A relative afferent pupillary defect was present in all cases of invasive fungal sinusitis. Surgical interventions were performed in 63 out of 64 cases. All the ophthalmological manifestations were reversible except for patients with invasive fungal rhinosinusitis., Conclusion: Orbital complications of RS may require early surgical intervention with multidisciplinary counseling between ophthalmologists, otorhinolaryngologists, radiologists, and neurologists.

Background: Acute invasive fungal sinusitis (AIFS) is an aggressive and dangerous disease of the paranasal sinuses with high morbidity and mortality. The immune response at the level of the nasal mucosa, the site of entry, has not been previously evaluated., Objective: To evaluate differential gene expression in the sinonasal mucosa of AIFS patients as compared to control patients using RNA sequencing., Methods: Sinonasal tissue samples were prospectively obtained from consenting patients undergoing surgery between November, 2020 and November, 2021. RNA extraction and sequencing were performed and differential expression was analyzed to detect transcriptional differences between patient groups., Results: Tissue samples were collected from 4 patients with active AIFS diagnoses, 2 patients with recovered AIFS, 1 patient with a diagnosis of non-invasive fungal ball, and 4 healthy controls. 255 genes were differentially expressed in AIFS patients as compared to control patients. Specific Gene Ontology (GO) biological processes that were identified as differentially expressed in AIFS patients as compared to controls included the following: 1. GO:0007155 (cell adhesion), 2. GO:0030199 (collagen fibril organization) and 3. GO:0001525 (angiogenesis)., Conclusion: Transcriptional differences were noted between AIFS and control patients in sinonasal tissue samples. Future work is necessary to determine causes of the differential gene expressions between AIFS and control patients, specifically those who are immunosuppressed, or with preexisting non-invasive forms of fungal sinusitis, to guide treatment and prevention strategies.

Acute invasive fungal rhinosinusitis (AIFR) is a rare disease, but the prognosis is by no means ideal. Pathologically, fungal infection is not only located in the sinus cavity, but also invades the sinus mucosa and bone wall, the surrounding structures and tissues such as the orbit and anterior skull base are often compromised and are accompanied with intracranial and extracranial complications. Despite decades of efforts, acute invasive fungal rhinosinusitis remains a devastating disease, the mortality of the disease continues to hover around 50%. The main impediments to improving the prognosis of acute invasive fungal rhinosinusitis are the difficulties of early diagnosis and the rapid reversal of immune insufficiency. Moreover, aggressive surgery combined with systemic antifungal therapy are significant positive prognostic factors as well. Progress and standardization of AIFR treatment protocols have been limited by the scarcity of the disease and the absence of published randomized studies. Therewith, how to improve the therapeutic outcome and reduce the mortality rate has always been a challenging clinical discussion. We have summarized the relevant case series and literature from the recent years, management with optimal diagnostic and curative strategies are reviewed., Competing Interests: Declaration of competing interest The authors declare that they have no competing interests., (Copyright © 2022 Asian Surgical Association and Taiwan Robotic Surgery Association. Published by Elsevier B.V. All rights reserved.)

Treatment of patients with fungal sinusitis, in some cases, does not lead to complete sinus sanitation, which may be due to insufficient surgical intervention and/or incorrectly selected antimycotic therapy. Treatment of such patients must necessarily include the complete removal of fungal masses from the affected sinus and the further use of antimycotics that ensure complete elimination of the pathogen. A clinical case of chronic fungal operated isolated sphenoiditis caused by the fungus Schizophyllum commune is presented. For extensive drainage of the sphenoid sinus, the patient underwent translamellar sphenoidotomy on the right with further antifungal therapy.

The number of cases of children's sinogenic orbital complications does not reduce in spite of the advanced methods of paranasal sinuses visualization, wide use of antibacterial therapy against sinusitis, and preventive vaccination against pneumococcal disease. Orbital complications are more common with children than with adults, the basic reason of their development being ethmoiditis. The prevailing classification of orbital complications proposed by J. Chandler et al. divides these into preceptal and postceptal forms and gives description to 5 development stages of orbital complications in the order of their increasing severity. At an early age preceptal and orbital cellulites prevail, and these commonly need conservative treatment only. In case of orbital cellulitis, the major treatment method is endovenous antibiotic therapy in which the chosen antibiotic is to cover the whole spectrum of aerobic and anaerobic microbes often extracted in such cases. At small subperiostal abscesses (<0.5-1 ml), conservative treatment during 24-48 hours is possible. If there is no positive dynamics, or abscess grows in size, or eye symptoms progress, abscess and affected sinuses drain is recommended. Orbital abscess is to be given surgical treatment; at the same time endoscopic management of paranasal sinuses might by complemented with external surgical approaches (lateral and medial orbitotomy).

Currently, the problem of acute rhinosinusitis continues to be relevant due to the frequent occurrence of this pathology. A certain difficulty is caused by the differential diagnosis of viral, post-viral and bacterial forms of rhinosinusitis, which carries the risks of irrational therapy. The authors of the article discuss the role of a viral infection in the etiology and pathogenesis of acute rhinosinusitis, the stages in the development of an inflammatory reaction on the mucous membrane of the nose and paranasal sinuses, and the disruption of mucociliary clearance. The authors consider options for the pathogenetic therapy of postviral sinusitis, concluding that the use of local combined preparations containing the mucolytic acetylcysteine and the vasoconstrictor component of tuaminoheptane sulfate is effective.

Objective: To determine risk factors affecting mortality in acute invasive fungal sinusitis., Method: This observational cohort study was conducted over a five-year period., Results: Of 109 recruited patients, 90 (82.6 per cent) had diabetes mellitus. Predominant fungi were zygomycetes (72.6 per cent) with Rhizopus arrhizus being most common. Of the patients, 12.8 per cent showed a positive biopsy report from radiologically normal sinuses. Factors affecting mortality on multivariate analysis were: female sex ( p = 0.022), less than two weeks between symptoms and first intervention ( p = 0.01), and intracranial involvement ( p = 0.034). Other factors significant on univariate analysis were: peri-orbital swelling ( p = 0.016), restricted ocular movements ( p = 0.053), intracranial symptoms ( p = 0.008), posterior disease ( p = 0.058), imaging showing ocular involvement ( p = 0.041), fungus being zygomycetes ( p = 0.050) and post-operative cavity infection ( p = 0.032). Bilateral, palatal and retromaxillary involvement were not associated with poor prognosis., Conclusion: Diagnosis of acute invasive fungal sinusitis requires a high index of clinical suspicion. Recognition of factors associated with poor prognosis can help when counselling patients, and can help initiate urgent intervention by debridement and antifungal therapy. Post-operative nasal and sinus cavity care is important to reduce mortality.

Background: Chronic adenoiditis (CA) and chronic rhinosinusitis (CRS) present with similar symptoms, but an accurate diagnosis is critical for optimal treatment. We aim to differentiate CRS and CA based on sinonasal symptoms using the Sinus and Nasal Quality of Life Survey (SN-5) in children., Methods: This is a retrospective cohort study. Children (age 12 and younger) presenting with chronic sinonasal symptoms were divided into 2 groups based on CT scan sinus findings: CA group included patients with CT Lund-Mackay (LM) score <5 and CRS group included patients with CT LM score of 5 and more. SN-5 scores for each group were then compared, and both groups were compared to a control group. Other demographic data were also collected and analyzed., Results: There were 27 patients in the CA group, 42 patients in CRS group and 38 patients in the control group. Mean SN-5 scores were 2.03±0.71 for the control group, 3.49±1.00 for the CA group, and 4.53±0.77 for the CRS group (p < 0.0001); Statistical significance persisted when CA and CRS were compared in subset analysis (p < 0.0001). CT LM score was 2.70±2.07 for the CA group and 9.94±3.46 for the CRS group (p < 0.0001). Rates of asthma, allergic rhinitis, and smoke exposure differed between the three groups (p < 0.01), but they were not statistically different when CA and CRS were compared in subset analysis., Conclusion: Children with CRS have higher SN-5 score than children with CA. SN-5 score can be used to help otolaryngologists differentiate between these two clinical entities., Competing Interests: Declaration of competing interest None., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: Rhinosinusitis involves inflammation within the paranasal sinuses and the nasal mucosa. It is a very common chronic health condition. This paper performs a validation process on the Persian translation of the rhinosinusitis quality-of-life questionnaire (RhinoQOL), for use in clinical assessment of chronic rhinosinusitis (CRS) patients. The Lund-Mackay score is also used widely in assessing CRS, and this study aims to describe its relationship to RhinoQOL., Methods: The Persian RhinoQOL adaptation was carried out on 110 CRS patients. A follow-up questionnaire was completed two weeks later. Psychometric properties were determined by statistical analysis (reliability, reproducibility, validity, responsiveness). A total of 45 patients were included for radiologic score calculation. The Spearman's test was used for assessing the correlation between the RhinoQOL scores and Lund-Mackay score., Results: Internal reliability was excellent for the impact scale (Cronbach's alpha=0.92). Cronbach's alpha was 0.63 and 0.55 for frequency and irritation scales, which reflects lower internal consistency values. Temporal stability or Test-retest reliability was excellent across all three scales. ICC was 0.96, 0.97, and 0.99 for RhinoQOL frequency, irritation, and impact scales. No significant correlation was observed between the Lund-Mackay score and RhinoQOL scores in terms of frequency, irritation and impact scales., Conclusion: The Persian version of RhinoQOL appears to be as reliable, valid, and sensitive to change as the English version., (2022 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Chronic rhinosinusitis (CRS) is an inflammatory condition of the paranasal sinuses defined by classic symptoms, imaging findings, 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, including 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 on the efficacy and risks of these available therapies. Allergists-immunologists now have various therapies available to treat patients with CRS., (Copyright © 2021. Published by Elsevier Inc.)

Purpose: Chronic rhinosinusitis (CRS) is a highly prevalent multifactorial disorder. Culture-directed antibiotics are frequently prescribed to patients with CRS and the middle nasal meatus (MM) is traditionally believed to be a representative sampling site of the sinuses as a whole. The purpose of our study was to reevaluate the reliability of the MM as a sampling site in patients with CRS who suffer from impaired drainage from the sinuses to the MM., Methods: Swabs and tissue biopsies were collected from the MM, maxillary sinus and frontal sinus from 50 patients with CRS. The results of bacterial culture were compared between sampling methods and sites in relation to the patency of the sinus ostia., Results: 782 bacterial isolates were cultured from the samples. Concordant results between the MM and the sinus cavity were noted in 80% of patients for the maxillary sinus, but only 66% for the frontal sinus and 76% for the sinuses a whole. The differences were similarly prevalent in patients with open and occluded sinus ostia. Notably, swabs from all three sites provided representative information in 92% of patients and tissue biopsies did not provide additional information compared to multiple swabs., Conclusion: The traditional method of sampling from the middle meatus provides inadequate information in 24% of patients with CRS, which may result in inadequate antibiotic therapy and contribute to increasing antibiotic resistance. Additional sampling from the sinuses should be recommended whenever possible, while invasive sampling is not necessary., (© 2021. The Author(s).)

Purpose of Review: Allergic fungal rhinosinusitis (AFRS) is a debilitating condition for children. Despite there being several reviews on this topic in the adult population, there is a paucity of reviews of AFRS in the pediatric literature. This article reviews the recent evidence of pediatric AFRS with the aim to optimize outcomes of pediatric patients with this condition., Recent Findings: AFRS is clinically characterized by nasal polyposis, a type I hypersensitivity to fungal epitopes, very thick eosinophilic mucin, and peripheral eosinophilia. Pediatric AFRS has similar clinical characteristics to that in adults but is thought to have a more aggressive nature, with higher serum immunoglobulin E and more frequently bone erosion and malformation of facial bones. Diagnosis of pediatric AFRS is made by using the Bent and Kuhn's criteria developed for adult AFRS. The mainstay of treatment is surgery followed by postoperative corticosteroids. Adjunctive therapies, including topical/oral antifungal agents, allergen immunotherapy and biologics may improve outcomes in pediatric AFRS, but to date the current evidence is limited., Summary: To optimize the outcome of pediatric AFRS, adequate and early diagnosis and treatment are essential. Appropriate and comprehensive endoscopic sinus surgery to open the sinuses, remove the fungal burden of disease and improve access of the sinuses to postoperative topical corticosteroid remains the standard of care., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Sinus fungal ball (SFB) is the most common type of non-invasive fungal sinusitis and develops mostly in immunocompetent individuals, whereas invasive fungal sinusitis (IFS), with high mortality, develops mostly in immunocompromised patients. SFB may progress to IFS depending on the patient's immune status and underlying diseases., Objectives: To investigate the possibility of SFB progressing to IFS., Patients/methods: A total of 10 patients histopathologically diagnosed with concurrent IFS and SFB from January 2013 to December 2019 were enrolled. Their clinical characteristics, histopathology and clinical course information were obtained and compared with those of 56 patients with IFS alone and 617 patients with SFB alone., Results: Acute, chronic and chronic granulomatous IFS was diagnosed in two (20%), five (50%) and three (30%) patients, respectively. All patients had severe facial pain and/or headache, with the most common comorbidity being diabetes (n = 5, 50%). SFB was identified in the maxillary (60%) and sphenoid (40%) sinuses. The tissue culture was positive for Aspergillus species in five (50%) patients. Eight patients with chronic or chronic granulomatous IFS were successfully treated by debridement with voriconazole, and the two patients with acute IFS and severe neutropenia due to haematologic malignancy died. Compared to patients with IFS alone, patients with combined SFB and IFS were older, female dominant, and commonly had chronic or chronic granulomatous IFS. In addition, they were older and more commonly diabetic and immunocompromised than patients with SFB alone., Conclusions: SFB may progress to IFS particularly in elderly and immunocompromised patients., (© 2021 Wiley-VCH GmbH.)

Background: Odontogenic sinusitis affects a significant proportion of patients with paranasal sinus infections. Nevertheless, no shared diagnostic criteria for this condition have yet been implemented and published studies differ in their definition of the disease., Objective: The present systematic review of the literature was undertaken to characterize and analyze the different diagnostic criteria currently employed for odontogenic sinusitis., Methods: Systematic searches for studies published between 2009 and 2019 were performed in Medline, Embase, Web of Science, Cochrane Library, and ClinicalTrials.gov databases. Search criteria were designed to identify all studies focusing, even partially, on odontogenic sinusitis. Human original studies except single case reports published in the English, French, German, Spanish, or Italian language were included. We removed duplicate abstracts and conducted full-text reads, data extraction, and quality assessment procedures (using the Oxford Centre for Evidence-based Medicine levels of evidence and National Heart Lung and Blood Institute Study Quality Assessment Tools). We reviewed articles for diagnostic criteria, both in terms of definition and etiology identification., Results: Among 1,000 unique citations, 63 studies were deemed eligible. Most articles (n = 45) were retrospective case series; a single randomized clinical trial was available. Only 49 studies reported diagnostic criteria, yet relied marginally on published guidelines (n = 10 articles) for identifying sinusitis, often choosing instead to develop their own clinical (n = 15 articles), endoscopic (n = 12 articles), and/or radiologic (n = 30 articles) criteria. For odontogenic focus identification, 14 papers required a multidisciplinary evaluation, 11 papers required a time relationship between dental procedures and sinusitis, 24 papers required oroscopy and/or dental evaluation, and 53 papers required computed tomography., Conclusions: Current diagnostic criteria for odontogenic sinusitis are extremely heterogeneous. Establishing shared diagnostic criteria aimed at defining both sinusitis and related odontogenic foci would spur collaboration between investigators and support more comprehensive outcomes evaluations together with a better understanding of treatment options.

Objective: To study the possible association between invasive fungal sinusitis (mucormycosis) and coronavirus disease., Methods: A prospective observational study was conducted at a tertiary care centre over four months, involving all patients with mucormycosis of the paranasal sinuses suffering from or having a history of coronavirus disease infection., Results: Twenty-three patients presented with mucormycosis, all had an association with coronavirus disease 2019. The ethmoids (100 per cent) were the most common sinuses affected. Intra-orbital extension was seen in 43.47 per cent of cases, while intracranial extension was only seen in 8.69 per cent. Diabetes mellitus was present in 21 of 23 cases, and was uncontrolled in 12 cases. All patients had a history of steroid use during their coronavirus treatment., Conclusion: New manifestations of coronavirus disease 2019 are appearing over time. The association between coronavirus and mucormycosis of the paranasal sinuses must be given serious consideration. Uncontrolled diabetes and over-zealous use of steroids are two main factors aggravating the illness, and both of these must be properly checked.

Background: Common sinonasal disorders include chronic rhinosinusitis (CRS), allergic rhinitis (AR), and a deviated nasal septum (DNS), which often coexist with shared common symptoms including nasal obstruction, olfactory dysfunction, and rhinorrhea. Various objective outcome measures and patient-reported outcome measures (PROMs) are used to assess disease severity; however, there is limited evidence in the literature on the correlation between them. This systematic review aims to examine the relationship between them and provide recommendations., Methods: A search of MEDLINE and EMBASE identified studies quantifying correlations between objective outcome measures and PROMs for the sinonasal conditions using a narrative synthesis., Results: In total, 59 studies met inclusion criteria. For nasal obstruction, rhinomanometry shows a lack of correlation whereas peak nasal inspiratory flow (PNIF) shows the strongest correlation with PROMs (r > 0.5). The Sniffin' Stick test shows a stronger correlation with PROMs (r > 0.5) than the University of Pennsylvania Smell Identification Test (UPSIT) (r < 0.5). Computed tomography (CT) sinus scores show little evidence of correlation with PROMs and nasal endoscopic ratings (weak correlation, r < 0.5)., Conclusion: Overall, objective outcome measures and PROMs assessing sinonasal symptoms are poorly correlated, and we recommend that objective outcome measures be used with validated PROMs depending on the setting. PNIF should be used in routine clinical practice for nasal obstruction; rhinomanometry and acoustic rhinometry may be useful in research. The Sniffin' Sticks test is recommended for olfactory dysfunction with UPSIT as an alternative. CT scores should be excluded as a routine CRS outcome measure, and endoscopic scores should be used in combination with PROMs until further research is conducted., (© 2020 The Authors. International Forum of Allergy & Rhinology published by Wiley Periodicals LLC on behalf of American Academy of Otolaryngic Allergy and American Rhinologic Society.)

Case Presentation: A 14-year old girl presented with history of productive cough since the age of 3 years. For the past 6 years, she complained of chest tightness and wheezing. There was also nasal stuffiness and discharge for the past 6 years. She denied history of hemoptysis, ear discharge, or chest pain. There was no history of respiratory distress at the time of birth. Her brother also suffered from productive cough and wheezing since the age of 3 years. However, both her parents were asymptomatic., (Copyright © 2020 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Objective: The 22-item Sinonasal Outcome Test (SNOT-22) is a trusted measure of symptom severity in chronic rhinosinusitis. The European Position Paper on Rhinosinusitis (EPOS) provides widely accepted diagnostic criteria, which include sinonasal symptoms, their duration, and imaging results. Our objective was to compare these approaches to assessing symptoms to determine if either was more indicative of radiologic findings, to support decisions in telehealth., Study Design: Observational outcomes study., Setting: Tertiary care center., Methods: In total, 162 consecutive patients provided a structured sinonasal history, completed the SNOT-22, and underwent sinus computed tomography (CT) within 1 month. SNOT-22 scores, EPOS-defined symptom sets, and Lund-Mackay results were assessed. To facilitate direct comparisons, we performed stepwise evaluations of sinonasal symptoms alone and combined with duration. The discriminatory capacity for imaging results was determined through areas under the receiver operating characteristic curves (ROC-AUC) for dichotomous outcomes and ordinal regression for multilevel outcomes., Results: In ROC-AUC analyses, SNOT-22 and EPOS-defined symptoms had similar discriminatory capacity for Lund-Mackay scores, regardless of duration. Within ordinal regression analyses, SNOT-22 nasal scores were significantly associated with Lund-Mackay scores, while EPOS-defined nasal symptoms were not statistically significantly related., Conclusions: SNOT-22 nasal scores and EPOS-defined nasal symptoms may have similar associations with imaging results when assessed via ROC-AUC, while SNOT-22 may have more association within ordinal data. Understanding the implications of discrete patterns of symptoms may confer benefit, particularly when in-person and fiberoptic exams are limited.

Inflammation of the paranasal sinuses significantly reduces the quality of life of people and causes marked economic damage to society. The striking clinical picture of sinusitis has always forced doctors to study the disease, as evidenced by the first records of the anatomy and diseases of the paranasal sinuses by doctors in ancient Egypt more than 3.000 years BC. Sinusitis has been treated in different ways in different historical periods. Effective medication treatment appeared relatively recently and began to steadily replace the older instrumental methods, to which many people had a preconceived notion of invasiveness. However, many studies are showing the positive effect of active drainage methods and, moreover, there is data showing that the discomfort during such procedures is slightly higher than during dental treatment under local anesthesia. This article presents a review of the available scientific literature on the use of different treatments for bacterial rhinosinusitis at different historical stages, ranging from the first publications on puncture techniques to balloon dilatation and the modern approach to conservative treatment.

Inflammation of the paranasal sinuses significantly reduces the quality of life of people and causes marked economic damage to society. The striking clinical picture of sinusitis has always forced doctors to study the disease, as evidenced by the first records of the anatomy and diseases of the paranasal sinuses by doctors in ancient Egypt more than 3.000 years BC. Sinusitis has been treated in different ways in different historical periods. Effective medication treatment appeared relatively recently and began to steadily replace the older instrumental methods, to which many people had a preconceived notion of invasiveness. However, many studies are showing the positive effect of active drainage methods and, moreover, there is data showing that the discomfort during such procedures is slightly higher than during dental treatment under local anesthesia. This article presents a review of the available scientific literature on the use of different treatments for bacterial rhinosinusitis at different historical stages, ranging from the first publications on puncture techniques to balloon dilatation and the modern approach to conservative treatment.

Mucormycosis is an aggressive, angioinvasive fungal infection with a predilection for the rhino-orbital cavity, predominantly in immunocompromised patients such as patients with uncontrolled diabetes. Prognosis is very poor, with a survival rate of 40% to 50%; therefore, early detection and initiation of treatment is paramount. Presenting symptoms are vague and mucormycosis is rare, so recognition, awareness, and knowledge of this infection are key to timely intervention and enhanced patient survival.

Objective: To determine whether psychological status is an effect modifier of the previously observed low discriminatory capacity of Sinonasal Outcome Test-22 (SNOT-22) scores for Lund-Mackay computed tomography (CT) results., Study Design: Observational outcomes study., Setting: Tertiary care center., Subjects and Methods: We assessed patients presenting with chronic sinonasal complaints who underwent CT of the sinuses within 1 month of completing the SNOT-22 instrument. SNOT-22 overall and domain scores were calculated, as were Lund-Mackay CT scores. The discriminatory capacity of SNOT-22 scores for CT results was determined using the receiver-operator characteristic area under the curve (ROC-AUC). Patient-Reported Outcome Measurement Information System (PROMIS) mental health T-scores were assessed, and stratified analyses were used to test for effect modification by psychological status., Results: In stratified analyses, patients with better PROMIS mental health scores had SNOT-22 overall (ROC-AUC 0.96) and nasal domain scores (ROC-AUC 0.97-0.98) that were highly discriminatory for Lund-Mackay scores, while those with worse mental health scores did not (ROC-AUC 0.42-0.55, P < .007). Patients with better SNOT-22 psychological domain scores also had nasal scores that discriminated among CT results significantly better than those with worse psychological domain scores (ROC-AUC 0.65-0.69 and 0.34-0.35, respectively, P < .013)., Conclusions: Psychological status is an effect modifier of the relationship between SNOT-22 and Lund-Mackay scores. SNOT-22 scores were discriminatory for Lund-Mackay CT results in patients with better psychological status, while they were nondiscriminatory in those with worse psychological status. When assessing the relationship between subjective and objective measures of chronic rhinosinusitis, accounting for effect modification may have practical utility.

Over the last three decades, functional endoscopic sinus surgery (FESS) has become one of the most common surgical techniques, with significant data supporting its efficacy in treating chronic rhinosinusitis (CRS). However, despite this initial published success rate, approximately 10-15% of them will require a subsequent revision surgery. The severity of the disease, the comorbidities and the anatomical variation that are not addressed adequately in the primary surgery, are considered the main factors that cause the failure of the primary surgery. Our objective is to report anatomical findings that may contribute to recurrent disease to improve the success rate in the primary surgery. PATIENTS AND METHODS: A prospective cross sectional study was conducted for 24 patients presenting for revision functional endoscopic sinus surgery (FESS). Lund-kennedy and Lund-Mackay score systems, pre and intraoperative CT scan and endoscopic assessments utilized, respectively, to delineate the causes of the primary surgery's failure. The most common finding was persistent frontoethmoidal cell, anterior and posterior ethmoid cell: 81.2%, 72.9%, 70.8%, respectively. Bony osteitis and scarred frontal recess were visible in 66.7%. Recirculation phenomena, resected concha bullosa and persistent Onodi cell, were the least noticeable findings: 6.25%, 8.3%, 8.30% consecutively CONCLUSIONS: The recurrence of the CRS that needs revision FESS is multifactorial in etiology ranging from sever mucosal disease to anatomical variations that is not addressed precisely in primary surgery. Trials of studies with a larger number of patient series comparing the anatomical variations that impact on recurrence of CRS with and without polyp are required.

Background: Previous research have suggested that chronic rhinosinusitis (CRS) patients with lower symptomatic scores, demonstrated by a 22-item Sinonasal Outcome Test (SNOT-22) score <20, may not achieve meaningful quality of life improvement following endoscopic sinus surgery (ESS). However, indications for ESS are continuing to be defined and many low SNOT-22 scoring patients still undergo elective surgery for CRS and other benign sinonasal pathologies. The outcomes for these patients have not been previously studied., Objectives: We sought to evaluate surgical indications and outcomes for those patients with limited symptoms undergoing ESS., Methods: We screened 2829 ESS procedures from 2010-2018 to identify patients with a preoperative SNOT-22 score <20. We reviewed disease characteristics, preoperative Lund-Mackay (LM) scores, and pre- and postoperative SNOT-22 scores in patients with at least 3 months' follow-up., Results: Of all surgical ESS patients screened, 114 had low preoperative SNOT-22 scores (4.0%). Indications for these surgeries included CRS (50.0%), odontogenic sinus disease (11.4%), mucocele (10.5%), recurrent acute sinusitis (7.0%), fungal ball (5.3%), and silent sinus syndrome (4.4%). Specifically, among CRS patients, 45.6% had pulmonary comorbidities and/or systemic immunodeficiencies. Moreover, 100% of CRS patients with nasal polyps and 73.1% of CRS without polyps had LM scores >5. Patients with preoperative SNOT-22 scores between 15 and 19 achieved an average 6.5 point reduction ( P  < .001) postoperatively, whereas those with scores between 10 and 14 had a 5.4 point reduction ( P  < .001), and preoperative scores <9 resulted in no significant decrease in postoperative symptom scores ( P  = .98). Overall, there was a 3.3 point SNOT-22 reduction among all patients at 3 months postoperatively ( P  < .001)., Conclusion: Patients with limited sinonasal symptoms may benefit from surgical treatment despite asymptomatic clinical presentations. A case-by-case analysis of comorbidities or unique clinical features should inform surgical decision-making for patients with lower SNOT-22 scores.

Objectives: In the past two decades, endoscopic sinus surgery (ESS) has been performed frequently in children with medically recalcitrant chronic rhinosinusitis (CRS). However, surgical success rates vary according to age. The causes of failure and prognostic factors for revision ESS remain unclear. The aims of the present study were to evaluate prognostic factors related to revision surgery after ESS, and to determine the most optimal timing for surgery in the pediatric population., Methods: This was a retrospective review in a tertiary medical center. Children who underwent ESS for CRS between 2004 and 2017 were enrolled. Demographics, sinonasal examination findings, previous operation history, laboratory data, comorbidities, and computed tomography (CT) results were collected from medical records. Prognostic factors for revision surgery were analyzed., Results: A total of 188 pediatric patients were enrolled in this study. Twenty-four patients (12.8%) required revision surgery. Multivariate logistic regression analysis identified patients with nasal allergy (OR = 6.258; P = .010) and higher Lund-Mackay score on preoperative sinus CT (OR = 1.658; P = .043) had worse outcomes, while older age was a positive prognostic factor (OR = 0.702; P = .018). A cut-off point of 15.68 years of age and mean Lund-Mackay score of 10.5 showed the best predictive power for revision surgery., Conclusion: Because ESS is performed with increasing frequency in children, knowledge of prognostic factors for revision surgery is important. In this study, patients with younger age, nasal allergy, and higher Lund-Mackay score on preoperative sinus CT had worse outcomes., Level of Evidence: 4 Laryngoscope, 130:1051-1055, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Purpose: Fungus ball (FB) is the most common type of fungal rhinosinusitis and the prevalence of FB has increased over the past 10 years. The aim of this study was to compare the clinical characteristics of Korean adult patients with FB and chronic rhinosinusitis (CRS) without FB., Methods: We retrospectively analyzed data on 1362 patients (147 FB and 1215 CRS) who underwent endoscopic sinus surgery at nine Korean medical centers in 2005, 2010, and 2016. We evaluated the prevalence of FB and compared the clinical characteristics of FB and CRS. Medical records, computed tomography (CT) findings, atopic status, concomitant diseases, tissue, and blood eosinophil count were assessed., Results: The prevalence of FB was significantly higher in 2016 (15.9%) than in the other years (7.8% in 2005 and 7.5% in 2010). The FB patients were more likely to be female, older, have unilateral disease and less likely to have allergy compared to the CRS patients. The most common main complaint related to CRS and FB was nasal obstruction. CT determined that unilateral disease and maxillary sinus dominancy were common in patients with FB. The incidence of concomitant diseases was much higher in FB, with lower tissue and blood eosinophilia., Conclusion: FB is commonly encountered in older women with the increased prevalence. FB had a different clinical presentation, radiological findings, and prognosis than CRS. Further studies are needed to understand the pathophysiologic mechanisms underlying the development of FB.

The number of cases of acute bacterial rhinosinusitis (ABRS) in our country tends to increase. According to clinical guidelines of the Ministry of Health of the Russian Federation, nasal catheter drainage is used to treat ABRS, but not all ENT-doctors use this method in daily practice. Many of them use it empirically and obtain good results., Goal: To study the experience of ENT-doctors using the YAMIK nasal catheter (NC) in their clinical practice., Material and Methods: To achieve the goal, a 16-question questionnaire was developed. Further, a survey of 30 ENT-doctors was conducted via e-mail., Results and Discussion: The study showed a marked dispersion of data regarding the time of starting therapy, the number of necessary procedures, as well as the components of medication solutions administered to the paranasal sinuses. At the same time, the effectiveness of the method, in doctors' opinion, is very high (above 90%). The incorrect technique of NC application, absence of studies according to the principles of Good Clinical Practice (GCP), and constructive disadvantages of NC may be probable reasons for the method undervaluation., Conclusions: The prescription of procedures with NC to patients with ABRS is empirical and is probably related to the absence of clear indications for such treatment, data on its duration, and associated therapy. Consequently, research following GCP principles is required to develop an algorithm for treating ABSR with an NC. The development of a new design for an NC that will allow each ENT-doctor to learn the method is also appropriate.

Objective: Total laryngectomy (TL) results in complete abolition of nasal airflow, with notable pathologic alterations of the intranasal mucosa, mucociliary clearance, and nasal cycle. Despite these observed morphological changes, it remains unclear whether this subpopulation of patients experiences clinically significant sinonasal disease. The goal of this study was to identify rhinosinusitis in TL patients using radiographic imaging., Methods: An Institutional Review Board-approved retrospective review (January 2005-July 2017) identified 50 patients who underwent radiographic imaging before and after TL. The Lund-Mackay Staging System (LM) was applied to 197 surveillance computed tomography scans. Surveyed patients also underwent investigation of current sinonasal symptomatology using the SNOT-22 questionnaire. Simple linear regression was modeled to LM scores; tests of statistical significance were estimated via the method of Kenward and Roger., Results: The mean age was 62.4 years, with a 5:1 male-to-female ratio. The mean SNOT-22 score was 27.4 (range, 5-33). A median of 3 scans was obtained, 49% within 12 months after TL. The mean (± standard deviation) postoperative LM score was 2.7 ± 3.97 points (range, 0-19). For every 1 month after TL, postoperative LM was +0.01 point ( P = .49). Conversely, for every +1 point in preoperative LM, postoperative LM was +1.08 points ( P < .001). Two patients required functional endoscopic sinus surgery after TL for persistent sinonasal disease., Conclusions: Preoperative sinonasal disease burden likely plays an important role in the development of clinically significant rhinosinusitis in TL patients. Correlating radiographic findings to validated outcome measures remains a critical aspect of determining optimal surgical candidates; this arena is still under investigation in this unique patient cohort.

Objective: The role of the microbiome in the etiology of chronic rhinosinusitis (CRS) is still in debate. Reductions in richness and diversity have been implicated in CRS; however, limited knowledge exists regarding the impact of the severity of disease on the microbiome. The associations between constituents of the microbiome and the degree of mucosal inflammation and tissue eosinophilia are described., Methods: A cross-sectional study of CRS and non-CRS patients who underwent endoscopic sinus surgery was performed. Sinus mucosal biopsies were assessed for the degree of inflammation and tissue eosinophilia. Middle-meatal swabs were subjected to 16S rRNA gene sequencing, which quantified the prevalence, mean relative abundance, richness, and diversity. Comparisons between the microbiome at the genus level and degree of inflammation (absent, mild, moderate, severe) and tissue eosinophilia (absent, < 10, 10-100, > 100 per high-powered field) were performed., Results: Eight-nine patients (52.8 ± 14.21 years, 64.0% male) were assessed. Of those, 52 had CRS and 37 were controls. Corynebacterium and Staphylococcus were the most abundant genera in both the CRS (29% and 16%) and non-CRS groups (40% and 20%). Richness decreased in more severely inflamed patients (23.2 ± 13.9 vs. 18.1 ± 16.1 vs. 16.8 ± 12.3 vs. 14.7 ± 10.9; P < 0.01), as did diversity (1.4 ± 0.7 vs. 1.2 ± 1.0 vs. 1.2 ± 0.8 vs. 0.9 ± 0.7; P = 0.05). Richness was associated with higher tissue eosinophilia (23.2 ± 13.9 vs. 19.3 ± 17.2 vs. 15.9 ± 11.6 vs. 13.4 ± 6.6; P < 0.01)., Conclusion: The loss of richness and diversity seen in the CRS microbiome appears to be a product of severity of inflammation and tissue eosinophilia. Whether this dysbiosis is causative or a result of the disease with impaired epithelial integrity requires ongoing research., Level of Evidence: 4 Laryngoscope, 129:1265-1273, 2019., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: Recent increases in opioid-related mortality have prompted a critical evaluation of postoperative pain management across all specialties. However, successfully limiting narcotic overprescription requires perioperative identification of patients who are at risk for high postoperative pain. Unfortunately, quality data to guide practice patterns are lacking. We therefore prospectively investigated several possible predictive factors of postoperative pain after endoscopic sinus surgery (ESS)., Methods: Sixty-four consecutive patients undergoing ESS were enrolled. Baseline 22-item SinoNasal Outcomes Test (SNOT-22) and Short-Form 8 (SF-8) scores were obtained. Pain scores were collected postoperatively using a numeric rating scale. Spearman correlations and univariate linear regression models were used to investigate relationships between postoperative pain, patient factors, and SNOT-22/SF-8 domain scores. Multivariate linear regression was then performed to control for potential confounding variables., Results: Day-of-surgery pain scores were significantly correlated with the SF-8 role-physical domain (Rs = 0.32, P = 0.04). Whereas SF-8 pain scores were initially nonsignificant, at postoperative day 3 (POD3) the preoperative SF-8 pain score became correlated with self-reported pain (Rs = 0.39, P = 0.02). SNOT-22 total and subdomain scores were not associated with pain scores at any time point. Multivariate linear regression modelling identified baseline SF-8 role-physical and pain scores, smoking status, and undergoing a modified Lothrop procedure as significant independent predictors of POD3 pain (adjusted R 2 = 0.359, P < 0.0001)., Conclusion: Baseline patient-reported global quality-of-life measures are associated with postoperative pain after ESS. Large multicenter studies are necessary to validate these findings and investigate additional factors associated with postoperative pain following ESS., Level of Evidence: 2c Laryngoscope, 129:1274-1279, 2019., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Purpose: Image-guidance systems (IGS) have gained widespread use in endoscopic sinus surgery (ESS) and have been thoroughly analysed. In this study, we looked for a new parameter to determine if patients could directly benefit from the use of IGS during primary ESS. We questioned if IGS could improve the quality of ESS in chronic rhinosinusitis (CRS) patients via allowing a more comprehensive treatment of all involved sinus compartments., Methods: In a pilot feasibility study, we evaluated uncomplicated CRS patients following primary ESS with and without IGS between January 2011 and June 2012 using preoperative and postoperative CT scans. The preoperative CT scans identified the sinus compartments requiring surgery. The postoperative CT scans were used to evaluate the treatment effect in these compartments. From these data, we calculated a missing ratio (missed compartments/compartments requiring surgery) for each patient., Results: Of the 169 ESS patients who were treated, ten patients were retrospectively identified as complying with the inclusion and exclusion criteria following ESS with IGS. Ten patients treated without IGS were then randomly chosen. The median missing ratio for non-IGS patients was 36%, and for IGS patients, the median missing ratio was 0% (p = 0.046). However, the missing ratio was depended on the number of compartments requiring surgery. Stratification of the number of compartments requiring surgery resulted in an exact p value of 0.13., Conclusions: IGS could help the surgeon to more completely address diseased sinus compartments. For better scientific merit, a comparative study of ESS with and without IGS seems feasible, using the proposed failing score missed compartments/compartments requiring surgery as the primary outcome parameter.

Background: The association between chronic rhinosinusitis (CRS) and chronic rhinitis remains unclear. The aim of this study was to estimate the predictive factors for sinus opacification in chronic rhinitis patients without obvious CRS., Methods: We retrospectively studied a total of 332 adult patients with chronic rhinitis who visited our clinic from January 2015 to December 2017. All of the patients underwent endoscopic examination, allergy test, and osteomeatal-unit computed tomography. The subjects were assigned to the normal sinus (NS) group (Lund-Mackay score [LMS] <5) and sinus opacification (SO) group (LMS ≥5)., Results: A total of 288 patients were eligible for this study. Of them, 183 (63.5%) were classified in the NS group and 105 (36.5%) in the SO group. Total immunoglobulin E (IgE) level and peripheral blood eosinophil count were significantly higher in the SO than NS group (p = 0.031 and p < 0.0001, respectively). Using Pearson correlation coefficients, we determined that eosinophil count had a positive correlation with the LMS (r = 0.282). In logistic analysis, the interquartile range increase (0.19 × 10 9 /L) of the eosinophil count was significantly associated with SO (odds ratio [OR] 1.76; 95% confidence interval [CI], 1.30 to 2.39). After adjusting for age, gender, smoking, drinking, and underlying disease, the interquartile range increase of the eosinophil count increased the odds of SO to 1.69-fold; this increase was statistically significant (p = 0.007; 95% CI, 1.17 to 2.43)., Conclusion: Peripheral blood eosinophil count is an independent predictor of CRS in patients with chronic rhinitis., (© 2018 ARS-AAOA, LLC.)

Purpose: Budesonide improves the prognosis of chronic rhinosinusitis (CRS). However, few reports have examined whether its use for nasal irrigation, compared to normal saline, improves the prognosis of patients after endoscopic sinus surgery (ESS). We compared the effects of nasal irrigation with budesonide and normal saline in CRS patients after ESS., Methods: Sixty CRS patients who had undergone ESS were randomly divided into an experimental group (30 patients), which used budesonide nasal irrigation, and a control group (30 patients), which used normal saline nasal irrigation. All patients received regular follow-up evaluations and were assessed via questionnaires, including the Lund-Kennedy endoscopic score (LKES), the symptom visual analog scale (VAS), the 22-item Sino-Nasal Outcome Test (SNOT-22), the Short-Form 36-Item Questionnaire (SF-36), the Self-Rating Anxiety Scale (SAS), the Self-Rating Depression Scale (SDS) and a side effects scale., Results: Scores of polyposis, mucosal edema, secretions and total score of LKES; VAS scores of nasal blockage, hyposmia and rhinorrhea; and SNOT-22 results in both groups were significantly improved 3 months after ESS. Scores of polyposis, mucosal edema, secretions and scarring and total score of LKES in experimental group were significantly better than in control group 3 months after ESS. No significant differences were observed in SF-36, SAS or SDS before or 3 months after ESS within or between the two groups. The side effects of the two groups were not significantly different., Conclusions: Nasal irrigation improved the prognosis of CRS patients after ESS. Budesonide nasal irrigation had a better effect than normal saline nasal irrigation.

Purpose: Many physicians recommend endoscopic sinus surgery (ESS) even when an asymptomatic paranasal sinus (PNS) fungal ball is detected incidentally. The aim of this study was to investigate the natural behavior of PNS fungal balls via sinus imaging techniques., Methods: A follow-up study of 74 pathologically confirmed fungus balls was conducted in 70 patients who underwent multiple head and neck computed tomography (CT) scans or magnetic resonance imaging (MRI). We investigated the changes in symptoms and lesion size, as well as any new occurrences., Results: Of the 74 fungus balls detected in 70 patients, we observed the renewed formation of a fungal ball in 21 patients, which was not present on initial imaging conducted over a period of 2-162 months. The fungal ball was already present in 53 patients on the initial screening, and the longest follow-up was 197 months (range 1-197 months). Of these 53 lesions, 29 lesions showed an increase in size (29/53, 54.7%), whereas 12 lesions were not associated with any clinical symptoms (12/53, 22.6%). In the 21 newly formed fungal balls, further development was observed in 10 lesions, with 4 lesions showing an increase in size. Thus, size increment occurred in 33 of the 57 fungus balls., Conclusions: The fungal balls can exist without local tissue invasion for up to 17 years and new formation of the fungal balls was observed even within 2 months, especially when accompanied by initial clinical symptoms of sinusitis.

Background: Odontogenic maxillary sinusitis (OMS) and rhinogenic sinusitis (RS) are the main types of chronic rhinosinusitis (CRS) and have a significant impact on health-related quality of life (HRQL), but the difference in HRQL and symptom presentation between them has not been specifically evaluated to date. Obejctive: Our aim was to compare patterns of symptoms and HRQL disease-specific domains in patients affected with these 2 types of CRS., Methods: A group of 201 patients with CRS (99 with rhinogenic and 102 with odontogenic origin) completed the Sino-Nasal Outcome Test 22 (SNOT-22) questionnaire before treatment. Data sets were analyzed by using principal component analysis (PCA) to identify a set of symptom components together with the items excluded from PCA, which were then analyzed for differences between patients with OMS and RS., Results: PCA of SNOT-22 items identified 5 components: "rhinologic," "extranasal rhinologic," "ear/facial," "sleep and functional disturbance," and "emotional disturbance." Sneezing was excluded from PCA and treated as separate outcome variable and was significantly worse in RS patients. Patients with OMS scored significantly higher scores with regard to emotional disturbance, while RS patients scored significantly worse in sleep and functional disturbance. The extra symptom "malodor" was the most different symptom and was significantly worse in OMS patients. The total SNOT-22 score was not significantly different between the groups., Conclusion: With controlling of covariates that may influence the severity of the disease, this study showed some significant differences in symptom patterns and HRQL impairment between patients with OMS and RS. Malodor is the most characteristic feature of OMS. Therefore, OMS should always be suspected in patients complaining of bad breath.

Background: Convolutional neural networks (CNNs) are advanced artificial intelligence algorithms well suited to image classification tasks with variable features. These have been used to great effect in various real-world applications including handwriting recognition, face detection, image search, and fraud prevention. We sought to retrain a robust CNN with coronal computed tomography (CT) images to classify osteomeatal complex (OMC) occlusion and assess the performance of this technology with rhinologic data., Methods: The Google Inception-V3 CNN trained with 1.28 million images was used as the base model. Preoperative coronal sections through the OMC were obtained from 239 patients enrolled in 2 prospective chronic rhinosinusitis (CRS) outcomes studies, labeled according to OMC status, and mirrored to obtain a set of 956 images. Using this data, the classification layer of Inception-V3 was retrained in Python using a transfer learning method to adapt the CNN to the task of interpreting sinonasal CT images., Results: The retrained neural network achieved 85% classification accuracy for OMC occlusion, with a 95% confidence interval for algorithm accuracy of 78% to 92%. Receiver operating characteristic (ROC) curve analysis on the test set confirmed good classification ability of the CNN with an area under the ROC curve (AUC) of 0.87, significantly different than both random guessing and a dominant classifier that predicts the most common class (p < 0.0001)., Conclusion: Current state-of-the-art CNNs may be able to learn clinically relevant information from 2-dimensional sinonasal CT images with minimal supervision. Future work will extend this approach to 3-dimensional images in order to further refine this technology for possible clinical applications., (© 2018 ARS-AAOA, LLC.)

According to JESREC criteria, definite eosinophilic chronic rhinosinusitis (ECRS) is postoperatively diagnosed based on over 70 eosinophils in high power magnification fields of the resected nasal polyps in patients with probable ECRS. Preoperative systemic administration with steroid is a standard practice, because it reduced intraoperative bleeding during endoscopic sinus surgery (ESS) in patients with ECRS. However, it was recently reported that systemic administration with steroid decreased the number of eosinophils in the nasal polyps, leading to a false negative diagnosis of definite ECRS. To overcome the risk, we have adopted short-term pre-operative systemic administration with low-dose of steroid and examined if our steroid administration makes a false-negative diagnosis. We performed a retrospective chart review of 42 patients with probable ECRS. Eleven patients were administered with 0.5 mg of bethametasone for 7 days before ESS, and other 31 patients were not administered. The average number of eosinophils in nasal polyps in patients who were administered with steroid was 188 ± 167, which was not different from 199 ± 149 in the patients who were not administered. These findings suggest that short-term preoperative administration with low-dose of steroid has few risk of a false-negative diagnosis of definite ECRS. J. Med. Invest. 66 : 233-236, August, 2019.