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Chronic rhinosinusitis with nasal polyposis (CRSwNP) is associated with a significant disease burden. The optimal use of and administration route for intranasal corticosteroids (INCS) when managing CRSwNP are unclear.We systematically synthesized the evidence addressing INCS for CRSwNP.We searched studies archived in Medline, Embase, and Central from database inception until September 1, 2021, for randomized controlled trials comparing INCS using any delivery method to placebo or other INCS administration types. Paired reviewers screened records, abstracted data, and rated risk of bias (CLARITY revision of Cochrane Risk of Bias version 1 tool) independently and in duplicate. We synthesized the evidence for each outcome using random effects network meta-analyses. We critically appraised the evidence following the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) approach.We analyzed 61 randomized controlled trials (7176 participants, 8 interventions). Sinusitis-related quality of life might improve with INCS rinse (mean difference [MD] -6.83, 95% confidence interval [CI] -11.94 to -1.71) and exhalation delivery system (EDS) (MD -7.86, 95% CI -14.64 to -1.08) compared to placebo (both low certainty evidence). Nasal obstruction symptoms are likely improved when receiving INCS via stent/dressing (MD -0.31, 95% CI -0.54 to -0.08), spray (MD -0.51, 95% CI -0.61 to -0.41), and EDS (MD -0.35, 95% CI -0.51 to -0.18) (all moderate to high certainty) compared to placebo. We found no important differences in adverse effects among interventions (moderate certainty for INCS spray, very low to low certainty for others).Multiple delivery forms of INCS are viable therapeutic options for CRSwNP, resulting in improvement of patient-important outcomes. INCS via stent, spray, and EDS appear to be beneficial across the widest range of considered outcomes.

The European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS), latest version EPOS2020, and the International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS), latest version ICAR-RS-2021, assimilate thousands of articles on the topic of rhinosinusitis. Encompassing scores of subtopics and relying on the perspectives of many international experts, EPOS2020 and ICAR-RS-2021 reduce the existing data into consumable formats and create evidence-based recommendations. The approaches and findings are similar in many respects but have significant differences. This clinical commentary, authored by some of the principal authors of these documents, compares and contrasts EPOS2020 and ICAR-RS-2021, examining methodology, diagnostic and treatment recommendations, and each document's emphases. This commentary demonstrates that, through somewhat differing methodologies, the 2 documents arrive at largely similar conclusions. Those who care for patients suffering from rhinosinusitis will find the documents complementary and valuable in their differences as much as in their similarities.

BACKGROUND: In the 5 years that have passed since the publication of the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR-Allergic Rhinitis 2018), the literature has expanded substantially. The ICAR-Allergic Rhinitis 2023 update presents 144 individual topics on allergic rhinitis (AR), expanded by over 40 topics from the 2018 document. Originally presented topics from 2018 have also been reviewed and updated. The executive summary highlights key evidence-based findings and recommendation from the full document.METHODS: ICAR-Allergic Rhinitis 2023 employed established evidence-based review with recommendation (EBRR) methodology to individually evaluate each topic. Stepwise iterative peer review and consensus was performed for each topic. The final document was then collated and includes the results of this work.RESULTS: ICAR-Allergic Rhinitis 2023 includes 10 major content areas and 144 individual topics related to AR. For a substantial proportion of topics included, an aggregate grade of evidence is presented, which is determined by collating the levels of evidence for each available study identified in the literature. For topics in which a diagnostic or therapeutic intervention is considered, a recommendation summary is presented, which considers the aggregate grade of evidence, benefit, harm, and cost.CONCLUSION: The ICAR-Allergic Rhinitis 2023 update provides a comprehensive evaluation of AR and the currently available evidence. It is this evidence that contributes to our current knowledge base and recommendations for patient evaluation and treatment.

Background: Comorbid chronic rhinosinusitis (CRS) of adulthood is increasing among patients with cystic fibrosis (CF) due to improved median survival. However, little is known about the natural history of endoscopic sinus surgery (ESS) in this cohort. The objective of this study was to evaluate the revision rate of ESS and associated risk factors among adults with CRS and CF (CRSwCF). Methods: The Utah Population Database was queried for patients age >18 with CRS who underwent at least one ESS between 1996 and 2018. Demographic information and ESS history were collected and compared for CRSwCF versus CRS without CF (CRSsCF) using chi-square and t-tests. Risk factors for revision were analyzed using Cox proportional hazard models and logistic regression analysis. Results: A total of 34 050 patients (33 639 CRSsCF and 411 CRSwCF) were included in the final analysis. The mean duration of follow-up was 9.3 and 9.3 years, respectively ( P = .98). Adult patients with CF were significantly more likely to undergo revision ESS (18.7%) than those without CF (13.4%; P

These evidence-based guidelines support patients, clinicians, and other stakeholders in decisions about the use of intranasal corticosteroids (INCS), biologics, and aspirin therapy after desensitization (ATAD) for the management of chronic rhinosinusitis with nasal polyposis (CRSwNP). It is important to note that the current evidence on surgery for CRSwNP was not assessed for this guideline, nor were management options other than INCS, biologics, and ATAD. The Allergy-Immunology Joint Task Force on Practice Parameters formed a multidisciplinary guideline panel balanced to include the views of multiple stakeholders and to minimize potential biases. Systematic reviews for each management option informed the guideline. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to inform and develop recommendations. The guideline panel reached consensus on the following statements: (1) In people with CRSwNP, the guideline panel suggests INCS rather than no INCS (conditional recommendation, low certainty of evidence) (2) In people with CRSwNP, the guideline panel suggests biologics rather than no biologics (conditional recommendation, moderate certainty of evidence) (3) In people with aspirin (nonsteroidal anti-inflammatory drug) exacerbated respiratory disease, the guideline panel suggests ATAD rather than no ATAD (conditional recommendation, moderate certainty of evidence). The conditions for each recommendation are discussed in the guideline.

BACKGROUND The impact of multiple coexisting medical comorbidities on treatment outcomes in chronic rhinosinusitis (CRS) is unknown. In this study we sought to evaluate the effect of comorbidities on sinonasal quality of life (QOL) and general health utility values by utilizing the Functional Comorbidity Index (FCI) in CRS patients. METHODS Patients with CRS were prospectively enrolled in a cross-sectional study of medical and surgical therapies. The 22-item Sino-Nasal Outcome Test (SNOT-22) and Medical Outcomes Study Short-Form 6D (SF-6D) scores were recorded at enrollment and 6-month follow-up; Lund-Kennedy endoscopy and Lund-Mackay computed tomography scores were recorded at enrollment. The FCI was calculated using the electronic medical record. The impact of cumulative comorbidity burden on baseline and posttreatment outcomes was assessed using univariate and bivariate correlations. RESULTS A total of 428 participants with CRS were included. The average (mean standard ± deviation) FCI score was 3.03 ± 2.28 (range, 0-12). Significant linear correlations were identified between increasing FCI score and baseline SNOT-22 and SF-6D scores (R = 0.166, p = 0.001 and R = -0.245, p

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 Many adjunctive techniques exist for dacryocystorhinostomy (DCR), with varying levels of supportive evidence. METHODS Literature from PubMed, EMBASE, and Cochrane Databases was reviewed between January 1990 and January 2020 to examine evidence regarding the utility of adjunctive techniques to DCR, including mucosal flap preservation, concurrent septoplasty, stenting, topical mitomycin C (MMC), and 5-fluorouracil (5-FU), as well as perioperative antibiotics and steroids. Recommendations were made based on the evidence found. RESULTS Seven adjunctive techniques used in DCR were examined. The literature supported concurrent septoplasty when septal deviation is present. Silicone stents are recommended for external DCR approaches. MMC use is optional in external DCR and revision cases. The literature does not support the routine use of silicone stents or MMC in primary endoscopic DCR. Mucosal flap preservation is optional, with evidence showing comparable results with or without utilization. The level of evidence is limited for topical 5-FU, as well as perioperative antibiotic and steroid use. CONCLUSION Recommendations for adjunctive techniques to external and endoscopic DCR surgeries can be made based on the current literature. Higher-level studies are needed to better optimize perioperative approaches to DCR.

Background Drug-eluting implants are becoming increasingly popular in the treatment of chronic rhinosinusitis (CRS). A previous attempt to make an evidence-based recommendation was hindered by limited evidence and experience with these implants. Since that time, the body of literature discussing drug-eluting implants has grown rapidly. The objective of this study was to review drug-eluting implants designed for use in the sinonasal cavity through an evidence-based review with recommendations. Methods A systematic review of the literature was performed using PubMed, EMBASE, Cochrane Review, and gray literature databases from January 1990 through February 2019 to examine drug-eluting implants used in CRS. Benefit-harm assessments, value judgments, and recommendations were made based on the available evidence. Study exclusion criteria included studies unavailable in English and non-endoscopic sinus surgeries. All authors agreed on recommendations through an iterative process. Results Thirty-one studies were included in the final analysis. Absorbable drug-eluting implants achieved a high aggregate grade of evidence (A), with a recommendation for their use to be considered in carefully selected patients. Nonabsorbable drug-eluting implants were recommended against due to minimal evidence supporting clinical efficacy. Antibiotic and alternative drug-eluting implants lack sufficient evidence for recommendations. Conclusion Absorbable steroid-eluting implants are recommended for carefully selected patients with CRS. Additional research to define appropriate patient selection is needed.

The 2016 International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR:RS) is a collaborative distillation of available research and consensus recommendations for the management for chronic rhinosinusitis (CRS). However, implementation of the ICAR:RS recommendations in the reality of clinical practice is not clearly defined.An anonymous, web-based survey of the American Rhinologic Society membership was performed in October, 2018. Respondents were asked about the frequency that they recommended the various treatments reviewed in ICAR:RS in the context of medical management for CRS. A 7-point Likert-type scale assessed the frequency of treatment patterns.A total of 140 members completed the survey (response rate 11.9%). Seventy-two (51.4%) were in practice for 0 to 15 years, 61 (43.6%) completed a rhinology fellowship, and 73 (52.1%) worked in private practice. Disparate treatment patterns were reported for each of the therapies assessed for CRS, including those that were "recommended" or "recommended against" in ICAR:RS. Members with15 years of experience were more likely to use nasal saline irrigation. Fellowship-trained respondents reported a greater likelihood of using nasal saline irrigation and aspirin desensitization (for patients with aspirin-exacerbated respiratory disease). Practitioners in academic medicine were more likely to utilize aspirin desensitization than those in private practice. Surgeons performing100 sinus surgeries per year were more likely to use topical antibiotics.The range of reported treatment patterns identified in this study despite the availability of the ICAR:RS recommendations may suggest the need for improved standardization of CRS management.

Gill AS, Pulsipher A, Sumsion JS, et al. J Asthma Allergy. 2021;14:405– 413 The authors have advised that they missed including a Funding statement in their paper. The following statement should have been included on page 412 of the published paper. Funding This study was funded by the Flight Attendant Medical Research Institute (CIA160008 to J.A.A.). The authors apologize for this error. Read the original article

We compared the performance of the Abbott BinaxNOW COVID-19 antigen card to that of a standard reverse transcription-PCR (RT-PCR) assay (Thermo Fisher TaqPath COVID-19 Combo kit) for the detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in 2,645 asymptomatic students presenting for screening at the University of Utah. SARS-CoV-2 RNA was detected in 1.7% of the study participants by RT-PCR., We compared the performance of the Abbott BinaxNOW COVID-19 antigen card to that of a standard reverse transcription-PCR (RT-PCR) assay (Thermo Fisher TaqPath COVID-19 Combo kit) for the detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in 2,645 asymptomatic students presenting for screening at the University of Utah. SARS-CoV-2 RNA was detected in 1.7% of the study participants by RT-PCR. BinaxNOW identified 24 infections but missed 21 infections that were detected by RT-PCR. The analytical sensitivity (positive agreement) and analytical specificity (negative agreement) for the BinaxNOW were 53.3% and 100%, respectively, compared to the RT-PCR assay. The median cycle threshold (CT) value in the specimens that had concordant positive BinaxNOW antigen results was significantly lower than that of specimens that were discordant (CT of 17.6 versus 29.6; P

Amarbir S Gill,1 Abigail Pulsipher,1 Jorgen S Sumsion,2 Gretchen M Oakley,1 Laurie W Leclair,3 Heather Howe,3 Richard R Orlandi,1 Jeremiah A Alt1 1Division of Otolaryngology – Head and Neck Surgery, Department of Surgery, University of Utah, Salt Lake City, UT, USA; 2School of Medicine, University of Utah, Salt Lake, USA; 3Department of Pulmonology/Critical Care Medicine, University of Utah, Salt Lake City, UT, USACorrespondence: Jeremiah A AltDivision of Otolaryngology – Head & Neck Surgery, Department of Surgery, University of Utah School of Medicine, 50 North Medical Drive, Room 3C120, Salt Lake City, UT, 84132, USATel +1 801 585-7143Fax +1 801 585-5744Email jeremiah.alt@hsc.utah.eduBackground: Data regarding the inflammatory profile of patients with asthma and chronic rhinosinusitis (CRS-A) with (CRSwNP-A) and without (CRSsNP-A) nasal polyposis remain limited.Objective: Define and compare systemic transcriptional changes in patients with CRS-A to those with non-asthma-related CRS with (CRSwNP) and without nasal polyposis (CRSsNP).Methods: Thirty-four patients with CRS-A (n=19) and CRS (n=15) were prospectively enrolled into an observational study. Demographic information and subjective and objective disease severity measures were recorded. Multiplex gene expression analysis of mRNA extracted from peripheral blood was performed. A total of 594 genes associated with innate/adaptive immunity were analyzed using NanoString technology. Gene expression ratios were reported for genes that were differentially expressed among these cohorts. Linear regression analysis was used to compare the mRNA transcript copy numbers for each gene with disease severity.Results: There was no significant difference in age, gender, nasal polyposis, or health-related quality of life measures between the two groups (p> 0.05). HLA class II histocompatibility antigen, DRB3-1 beta chain (HLA-DRB3) was significantly upregulated in the peripheral blood of patients with CRSsNP-A compared to CRSsNP, whereas chemokine (C-C motif) ligands 4 (CCL4) and zinc finger protein helios (IKZF2) were significantly upregulated in CRSwNP-A compared to CRSwNP (p< 0.05).Conclusion: Patients with CRSsNP-A demonstrate a molecular endotype associated with a Th2-dominant inflammatory profile compared to CRSsNP. Patients with CRSwNP-A similarly demonstrate an overrepresentation of genes associated with Th2-driven inflammation compared to patients with CRSwNP.Keywords: chronic rhinosinusitis, asthma, gene transcription, inflammatory markers, nasal polyposis, endotype

BACKGROUND A recent analysis suggested potential narrowing of the gender gap in research productivity in the field of rhinology. This analysis did not, however, provide insight into how the genders are represented in the rhinologic literature. This study aimed to evaluate 11 years of literature to evaluate for gender differences in authorship position, collaborations, category and content of research, citations, and funding to gain perspective on how gender and authorship has changed over time. METHODS Authorship data for all articles on rhinologic subject matter published between January 1, 2008 and December 31, 2018 in four otolaryngology journals was collected. The gender of authors was determined by protocol. Category and content of research and funding status/source were additionally obtained. RESULTS Data were collected from 2666 articles. Gender of 14,510 authors was determined. Female authors accounted for 23% of the overall authors and male authors accounted for 77%. Female first authorship increased significantly over time, but there was no change in female senior authorship. The percentage of female authors steadily increased over time, whereas male authorship decreased slightly. Mixed gender teams were shown to be increasing in frequency. Women published more than expected in basic science and allergy and less than expected in skull base. On funded studies, women were significantly underrepresented as senior authors. CONCLUSION This study represents the first assessment of gender differences in the rhinology literature. Areas where female representation can improve include senior authorship, increased involvement in skull base publications, and increased funding.

BACKGROUND Chronic rhinosinusitis with asthma (CRS-A) has a significant impact on patient morbidity and quality of life. Nevertheless, little is known about the natural history of endoscopic sinus surgery (ESS) in this cohort. The objective of this study was to evaluate revision rates of ESS in CRS-A and identify risk factors associated with increased likelihood for revision surgery compared to those with CRS without asthma (CRS-alone). METHODS The Utah Population Database was queried for patients age >18 years with CRS who underwent at least 1 ESS between 1996 and 2018. Demographic information and history of ESS were collected and compared between CRS-A and CRS-alone using chi-square tests for categorical variables and t tests for continuous variables. Risk factors for revision surgery were analyzed using Cox proportional hazard models. RESULTS A total of 33,090 patients (7693 CRS-A and 25,397 CRS-alone) were included in the final analysis. Mean follow up was 9.8 years in CRS-A and 9.1 years in CRS-alone (p < 0.001). The revision rate among patients with CRS-A (21.5%) was twice that of CRS-alone (10.8%) (p < 0.001). Among patients with CRS, a history of allergy (p < 0.001), asthma (p < 0.001), and nasal polyposis (p < 0.001) was independently associated with increased risk of revision ESS. Patients with CRS-A and nasal polyposis were 6 times more likely to require revision surgery than those with CRS-alone (p < 0.010). CONCLUSION The rate of revision ESS in CRS-A was twice that of CRS-alone; patients with CRS-A and nasal polyposis were 6 times more likely to require revision than those with CRS-alone. ©2021 ARSAAOA, LLC.

The U.S. Food and Drug Administration (FDA) and Centers for Disease Control interim guidelines for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing list the patient self-collected anterior nares swab (ANS) as an acceptable alternative to the standard health care provider (HCP)

We prospectively compared healthcare worker-collected nasopharyngeal swabs (NPS) to self-collected anterior nasal swabs (ANS) and straight saliva for the diagnosis of COVID-19 in 354 patients. The positive percent agreement between NPS and ANS or saliva was 86.3% (95% CI: 76.7-92.9) and 93.8% (95% CI: 86.0-97.9), respectively. Negative percent agreement was 99.6% (95% CI: 98-100) for NPS vs. ANS and 97.8% (95% CI: 95.3 – 99.2) for NPS vs. saliva. NPS (n=80) and saliva (n=81) detected more cases than ANS (n=70), but no single specimen type detected all SARS-CoV2 infections.

We prospectively compared health care worker-collected nasopharyngeal swabs (NPS) to self-collected anterior nasal swabs (ANS) and straight saliva for the diagnosis of coronavirus disease 2019 (COVID-19) in 354 patients. The percent positive agreement between NPS and ANS or saliva was 86.3% (95% confidence interval [CI], 76.7 to 92.9%) and 93.8% (95% CI, 86.0 to 97.9%), respectively. The percent negative agreement was 99.6% (95% CI, 98.0 to 100.0%) for NPS versus ANS and 97.8% (95% CI, 95.3 to 99., We prospectively compared health care worker-collected nasopharyngeal swabs (NPS) to self-collected anterior nasal swabs (ANS) and straight saliva for the diagnosis of coronavirus disease 2019 (COVID-19) in 354 patients. The percent positive agreement between NPS and ANS or saliva was 86.3% (95% confidence interval [CI], 76.7 to 92.9%) and 93.8% (95% CI, 86.0 to 97.9%), respectively. The percent negative agreement was 99.6% (95% CI, 98.0 to 100.0%) for NPS versus ANS and 97.8% (95% CI, 95.3 to 99.2%) for NPS versus saliva. More cases were detected by the use of NPS (n = 80) and saliva (n = 81) than by the use of ANS (n = 70), but no single specimen type detected all severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections.

Antibiotic therapy has become an important adjunct in the management of recalcitrant chronic rhinosinusitis (CRS) because of some antibiotics' immunomodulatory properties even at subtherapeutic antimicrobial levels. Macrolide antibiotics, such as clarithromycin and azithromycin, decrease production of proinflammatory cytokines, impair neutrophil recruitment, inhibit bacterial biofilm formation, and improve mucus quality. Doxycycline, a tetracycline antibiotic, inhibits the activity of matrix metalloproteinases in CRS with nasal polyposis. This article reviews the clinical applications for macrolide and doxycycline use in CRS, considerations for dosing and duration of treatment, and important side effects and drug interactions associated with these medications.

BACKGROUND: Reported revision rates for endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) vary significantly. Several investigations examining revision rates for ESS have been limited by duration of follow up, academic centers, or small surgeon cohorts. The objective of this study was to define the long-term revision rates for ESS and to determine those unique patient factors that increase the risk of revision ESS. METHODS: The Utah Population Database was queried for Current Procedural Terminology codes for ESS from 1996 to 2016. Patient demographics and comorbid diagnoses were collected. Revision rates and risk factors for surgery were determined by Cox Proportional Hazard modeling. RESULTS: A total of 29,934 patients were identified, with a mean length of follow up of 9.7 years. The long-term revision rate was found to be 15.9%. The mean time between surgeries decreased with higher number of revision surgeries. The time between the 1(st) and 2(nd) surgery was 4.39 years and the time between the 4(th) and 5(th) surgery decreased to 2.18 years. Female gender, older age at first surgery, nasal polyps, comorbid asthma, allergy and a family history of CRS all increased the risk of requiring revision surgery (p

To survey patients following sinonasal surgery regarding postoperative pain and opioid use.Patients were surveyed for 4 days following sinus and/or nasal surgery regarding their pain level and use of prescribed opioids.Four academic medical centers and 1 private practice institution.Consecutive adult patients undergoing sinonasal surgery.A total of 219 subjects met criteria and were included for analysis; 134 patients (61%) took 5 or fewer combination oxycodone (5-mg) and acetaminophen (325-mg) tablets in the first 3 postoperative days, and 196 patients (89.5%) took fewer than 15. Fifty-one patients (23%) consumed no opioid pain medication. Opioid consumption was positively correlated with postoperative pain ( RAn evidence-based approach to postoperative pain control following sinonasal surgery that reduces the number of unused and potentially diverted opioids is needed. The current study suggests that 15 combination oxycodone (5-mg) and acetaminophen (325-mg) tablets provide sufficient pain control for 90% of patients in the immediate postoperative period following sinonasal surgery, irrespective of the specific procedures performed, use of acetaminophen, or use of systemic steroids. Smoking status may help surgeons predict which patients will require larger opioid prescriptions.

Background Recent years have witnessed significant expansion in office-based rhinology. This study assesses practice patterns of the American Rhinologic Society (ARS) membership regarding office-based rhinologic procedures. Methods A 24-item survey was disseminated to the ARS membership from March 15 to May 31, 2016. Results A total of 157 physicians (11.9%) completed the survey. Office-based rhinologic procedures were performed by 99% of respondents, with sinonasal debridements (99%), polypectomy (77%), and balloon sinus ostial dilation (56%) being the most common. During a typical month, the number of sinonasal debridements was 0–10 in 23%, 11–20 in 34%, 21–30 in 26%, and >30 in 18%. For polypectomy, 57% of the respondents utilized a microdebrider (reusable electric—24%, disposable vacuum-powered—21%, and both—12%), 36% endoscopic forceps, and 7% a combination of both. With respect to balloon ostial dilation, the frontal sinuses were the most frequently addressed (53%) followed by the maxillary (46%) and sphenoid (39%) sinuses. In-office ethmoidectomies, antrostomies, sphenoidotomies, and frontal sinusotomies without the use of the balloon were performed by 35%, 31%, 24%, and 21% of the respondents, respectively. Thirty percent of respondents used steroid-eluting sinus implants and 10% used computer-assisted surgical navigation in the office setting. Overall, 63% of respondents reported that the number of office-based rhinologic procedures they performed had increased over the last 5 years. Conclusions The present study illustrates the integration of office procedures into rhinologic clinical practice among ARS survey respondents. With ongoing technologic innovations, the scope of office-based rhinology will likely continue to expand in the years to come.

Objectives There is little consensus regarding the prognostic value of symptom duration in predicting clinical disease severity or quality-of-life (QOL) outcomes in patients with chronic rhinosinusitis (CRS). Our objectives were to: 1) determine if patients with longer symptom duration have worse preoperative disease severity and/or QOL, and 2) determine if delayed surgical intervention influences outcomes of endoscopic sinus surgery (ESS). Methods Patients diagnosed with CRS were prospectively enrolled into a multicenter cohort study and observed 14.7 (standard deviaton {SD} ± 4.8) months on average following primary ESS. Preoperative symptom duration was stratified into short-term ( 60 months). Disease severity was assessed using endoscopy and computed tomography. Disease-specific QOL was measured with the 22-item Sinonasal Outcome Test (SNOT-22) and Rhinosinusitis Disability Index. Adjusted bivariate and multivariate associations between symptom duration, disease severity, and QOL scores were evaluated. Results One hundred and thirteen patients met inclusion criteria with 35 patients lost to postoperative follow-up. No significant differences in preoperative disease severity or QOL scores were reported between symptom duration subgroups. Participants in the long-term symptom subgroup reported significantly greater mean postoperative improvement on SNOT-22 total scores (n = 28; -36.3[± 22.2]) compared to both short-term (n = 27; -23.4[SD ± 11.3]; P = 0.039) and middle-term (n = 23; -23.5[SD ± 20.1]; P = 0.050) subgroups. Postoperative QOL improvements in the long-term symptom subgroup remained significantly greater (P ≤ 0.036) after multivariate adjustment. Conclusions Symptom duration was not associated with mean preoperative disease severity or QOL. Patients with long-term symptom duration reported the greatest mean postoperative QOL improvement, suggesting that delayed surgical intervention may not reduce QOL improvements following ESS. Level of evidence 2c Laryngoscope, 129:303-311, 2019.

BACKGROUND Chronic rhinosinusitis (CRS) is associated with productivity losses exceeding US$13 billion annually. Although pain is well known to significantly affect patient productivity in other diseases, its economic impact on CRS-related lost productivity has not been examined. The objective of this study was to determine whether CRS-related facial pain correlates with lost productivity in patients with CRS. METHODS Seventy patients with CRS were enrolled in a cross-sectional investigation. Patients with a history of systemic inflammatory disease, ciliary dysfunction, chronic pain syndromes, migraines, and fibromyalgia were excluded. Pain was measured using the Brief Pain Inventory Short Form (BPI-SF) and the Short-Form McGill Pain Questionnaire (SF-MPQ). Presenteeism, absenteeism and lost work, and household and overall productivity were assessed. Regression analysis was performed to assess potential confounders, including depression. RESULTS Pain as measured with BPI-SF and SF-MPQ total scores correlated with all domains of productivity losses. Overall, lost productivity was significantly correlated with pain (R range, 0.354-0.485; p < 0.001). Presenteeism (reduced work efficiency) had the highest correlation with all of the overall pain scores (R range, -0.366 to -0.515; p < 0.001). Lost household productivity time was the least affected by pain (R range, 0.267-0.389; p < 0.05). These correlations remained statistically significant after regression analysis, which accounted for depression (p < 0.05). CONCLUSION A significant correlation exists between CRS-related facial pain and productivity losses in patients with CRS that is independent of depression. Facial pain has the strongest correlation with presenteeism, which is the main driver of productivity losses and indirect costs associated with CRS.

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.

Objective To determine if the introduction of a systematic preoperative sinus computed tomography (CT) checklist improves identification of critical anatomic variations in sinus anatomy among patients undergoing endoscopic sinus surgery. Study Design Single-blinded prospective cohort study. Setting Tertiary care hospital. Subjects and Methods Otolaryngology residents were asked to identify critical surgical sinus anatomy on preoperative CT scans before and after introduction of a systematic approach to reviewing sinus CT scans. The percentage of correctly identified structures was documented and compared with a 2-sample t test. Results A total of 57 scans were reviewed: 28 preimplementation and 29 postimplementation. Implementation of the sinus CT checklist improved identification of critical sinus anatomy from 24% to 84% correct ( P < .001). All residents, junior and senior, demonstrated significant improvement in identification of sinus anatomic variants, including those not directly included in the systematic review implemented. Conclusion The implementation of a preoperative endoscopic sinus surgery radiographic checklist improves identification of critical anatomic sinus variations in a training population.

BACKGROUND Chronic rhinosinusitis (CRS) is a highly prevalent inflammatory condition, with significant effects on morbidity and quality of life. Given that other chronic inflammatory conditions have been associated with increased mortality risk, we sought to evaluate the relationship between mortality and CRS including the influence of asthma. Our objective was to determine if CRS, with or without asthma, is associated with altered risk of mortality. METHODS Using a statewide population database, we retrospectively identified 27,005 patients diagnosed with CRS between 1996 and 2012, and 134,440 unaffected controls matched 5:1 on birth year and sex. Risk of mortality was determined from Cox models and Kaplan-Meier curves were used to compare survival. RESULTS A significant interaction between CRS and asthma status was observed in which CRS appeared to confer a protective effect in asthma patients. Asthma, when present, increased mortality in CRS-negative controls (p-interaction < 0.0001). Independent of asthma status, CRS patients exhibited a decreased mortality risk (hazard ratio [HR] = 0.80; 95% confidence interval [CI], 0.74 to 0.85) compared to controls. However, in patients diagnosed at or before the median age of CRS onset (42 years) independent of asthma status, survival was not improved (HR = 0.98; 95% CI, 0.81 to 1.18). Risk of mortality was greater in CRS with nasal polyps (n = 1643) compared to 25,362 polyp-negative CRS patients (HR = 1.38; 95% CI, 1.09 to 1.77). CONCLUSION CRS was associated with lower risk of mortality compared to controls, and appeared to mitigate increased mortality from asthma. We posit that better survival conferred by CRS may be secondary to treatment. However, the etiology of this relationship and the effect of CRS treatment on mortality are unknown.

To improve our appreciation of the burden of chronic rhinosinusitis (CRS) and to understand better how to ease that burden. The burden of CRS is high. At an individual level, this burden is due to rhinologic symptoms as well as more systemic symptoms. At a societal level, the indirect costs of CRS, mostly due to reduced productivity, are higher than the direct costs. Surgical treatment has been found to be effective in addressing both the individual and societal burdens. Endotyping is just beginning to usher in the potential for personalized, precision treatments in CRS. We understand much about the burden of CRS but more remains to be learned, especially as newer expensive treatments become available. By appreciating the high burden of CRS, we can fulfill our mission to effectively lift that burden.

Background Poor sleep has significant effects on health contributing to increased morbidity and mortality. The direct and indirect costs of sleep dysfunction total well in to the billions of dollars annually in the United States. Chronic rhinosinusitis (CRS) affects up to 16% of the US population and has been linked to poor sleep quality with up to three quarters of patients with CRS reporting poor sleep quality. There is a growing body of literature evaluating the relationship between sleep and CRS. In this review, we organize and present the current knowledge on the associations between sleep and CRS as well as identify areas for further investigation. Data sources A structured literature search from 1946 to 2016 was conducted in the English language using OVID MEDLINE database, PubMed, and EMBASE. Review methods Abstracts were reviewed for relevance and appropriate studies were included in the narrative review. Results Studies were analyzed and discussed as they pertained to the following categories of CRS and sleep: (1) subjective measures of sleep dysfunction, (2) objective measures of sleep dysfunction, and (3) outcomes on sleep quality following treatment of CRS. Articles on the pathophysiology of sleep dysfunction in CRS were separately reviewed. Conclusions An evolving body of research demonstrates that quality of sleep is compromised in the majority of patients with CRS. Following treatment of CRS, there is significant improvement in subjective sleep quality, but additional research investigating objective measures following treatment is still needed. Additionally, further investigation is required to better elucidate the underlying pathophysiology of the relationship between sleep dysfunction and CRS. Level of Evidence N/A.

The Cochrane Corner is a section in the journal that highlights systematic reviews relevant to otolaryngology–head and neck surgery, with invited commentary to aid clinical decision making. This installment features a pair of related Cochrane Reviews on intranasal steroids for chronic rhinosinusitis, which identify low- to moderate-quality evidence for a beneficial effect on overall symptoms, nasal congestion, and rhinorrhea. There is no evidence, however, to suggest superiority of any particular steroid preparation or drug delivery system. The related expert commentary should help clinicians make the best treatment decisions based on the studies and outcomes identified in these Cochrane Reviews.

Background The frontal sinus is considered the most challenging sinus to address surgically. There are no current classifications of the degree of surgical complexity of different frontal sinus configurations. The aim of this study is to develop a classification system of the degree of complexity of frontal recess surgery based on preoperative computed tomography (CT) scans. Methods Authors were asked to submit a classification system. These were circulated to all authors. Selection of the final 3 classifications was based on a majority consensus. These classifications were compared further for time-taken, ease-of-use, and interrater agreement. These were assessed by the authors on 10 CT scans representing a range of anticipated surgical difficulty. Results Out of 3 compared classifications, classification A was the quickest to score (1.44 minutes vs 1.57 minutes and 2.25 minutes), subjectively easiest (3.23 vs 4.07 and 5 on a visual analogue scale [VAS]), and had a moderate interrater agreement (0.52 vs 0.42 and 0.79). In addition, the grading of complexity was as good whether measurements were taken on the CT scans or whether size of the frontal ostium was visually estimated. Conclusion We propose a fast, easy classification to anticipate the complexity of surgery in the frontal sinus and recess, for patients undergoing primary surgery.

Objectives/Hypothesis Placement of tympanostomy tubes for recurrent or chronic otitis media is the most commonly performed ambulatory procedure in the United States. Etiologies have been speculated to be environmentally based, and studies have suggested a genetic component to the disease. However, no large-scale studies have attempted to define a familial component. The objective of this study was to determine the familial risk of otitis media requiring tympanostomy tubes (OMwTT) in a statewide population. Study Design Retrospective observational cohort study with population-based matched controls. Methods Using an extensive genealogical database linked to medical records, the familial risk of OMwTT was calculated for relatives of probands (46,249 patients diagnosed with OMwTT from 1996–2013) compared to random population controls matched 5:1 on sex and birth year from logistic regression models. Results The median age at time of tympanostomy tube placement was 1 year (interquartile range, 0–2 years). First-degree relatives of patients with OMwTT, primarily siblings, had a 5-fold increased risk of OMwTT (P < 10−16). Second-degree relatives were at a 1.5-fold increased risk (P < 10–15). More extended relatives (third, fourth and fifth degree) showed a 1.4-fold increased risk (P < 10−15). Conclusions In the largest population-based study to date, a significant familial risk is confirmed in OMwTT, suggesting otitis media may have a significant genetic component given the increased risk found in close as well as distant relatives. This could be influenced by shared environments given a five-times risk observed in siblings. Further understanding the genetic basis of OMwTT and its interplay with environmental factors may clarify the etiology and lead to better detection of disease and treatments. Level of Evidence 3b. Laryngoscope, 127:962–966, 2017

Background Depression, pain, and sleep disturbance is a symptom cluster often found in patients with chronic illness, exerting a large impact on quality of life (QOL). A wealth of literature exists demonstrating a significant association between depression, pain, and sleep dysfunction in other chronic diseases. This relationship has not been described in patients with chronic rhinosinusitis (CRS). Methods Sixty-eight adult patients with CRS were prospectively enrolled. Patients at risk for depression were identified using the Patient Health Questionnaire-2 (PHQ-2) using a cut-off score of ≥1. Pain experience was measured using the Brief Pain Inventory Short Form (BPI-SF) and the Short Form McGill Pain Questionnaire (SF-MPQ). Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). Results Forty-seven patients were at risk for depression. Significant positive correlations were found between total PSQI scores and all pain measures (R = 0.38-0.61, p ≤ 0.05) and between total PSQI scores and PHQ-2 scores (R = 0.46, p < 0.05). For patients at risk for depression, significant, positive correlations were found between pain measures, the total PSQI score, and the 3 PSQI subdomains (sleep latency, sleep quality, and daytime dysfunction; R = 0.31-0.61, p < 0.05). The relationship between pain and sleep dysfunction scores was not seen in the absence of depression. Conclusion Depression, pain, and sleep dysfunction are interrelated in patients with CRS. In the absence of depression, significant correlations between pain and sleep are not observed, suggesting that depression plays a key role in this interaction. Further research is needed to investigate the complex relationship between depression, pain, and sleep dysfunction in CRS.

Introduction: Appropriate indications for endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) are currently poorly defined. The lack of clear surgical indications for ESS likely contributes to the large geographic variation in surgical rates and contributes to reduced quality of care. The objective of this study was to define appropriateness criteria for ESS during management of adult patients with uncomplicated CRS. Methods: The RAND/UCLA appropriateness methodology was performed. An international, multi-disciplinary panel of 10 experts in CRS was formed and completed two rounds of a modified Delphi ranking process along with a face-to-face meeting. Results: A total of 624 clinical scenarios were ranked, 312 scenarios each for CRS with and CRS without nasal polyps. For adult patients with uncomplicated CRS with nasal polyps, ESS can be appropriately offered when the CT Lund-Mackay score is ≥ 1 and there has been a minimum trial of a topical intranasal corticosteroid plus a short-course of systemic corticosteroid with a post-treatment total SNOT-22 score ≥ 20. For adult patients with uncomplicated CRS without nasal polyps, ESS can be appropriately offered when the CT Lund-Mackay score is ≥ 1 and there has been a minimum trial of a topical intranasal corticosteroid plus either a short-course of a broad spectrum/culture-directed systemic antibiotic or the use of a prolonged course of systemic low-dose anti-inflammatory antibiotic with a post-treatment total SNOT-22 score ≥ 20. Conclusion: This study has developed and reported of list of appropriateness criteria to offer ESS as a treatment option during management of uncomplicated adult CRS. The extent or technique of ESS was not addressed in this study and will depend on surgeon and patient factors. Furthermore, these criteria are the minimal threshold to make ESS a treatment option and do not imply that all patients meeting these criteria require surgery. The decision to perform ESS should be made after an informed patient makes a preference-sensitive decision to proceed with surgery. Applying these appropriateness criteria for ESS may optimize patient selection, reduce the incidence of unwarranted surgery, and assist clinicians in providing high quality, patient-centered care to patients with CRS.

Objectives/Hypothesis Nasal obstruction is a cardinal symptom in diagnosing chronic rhinosinusitis (CRS), and decreased sleep quality (SQ) and quality of life (QOL) are commonly reported in CRS. It is, however, unclear what role nasal obstruction severity plays in this decreased SQ and QOL. Using validated instruments, we evaluated the relationship between nasal obstruction severity, SQ, and QOL. Study Design Prospective case series. Methods Patients with CRS refractory to standard medical therapy (n = 28) were prospectively enrolled and completed the Nasal Obstruction Symptom Evaluation (NOSE), Pittsburg Sleep Quality Index (PSQI), Rhinosinusitis Disability Index, and the 22-item Sinonasal Outcome Test. CRS disease severity was evaluated with computed tomography and endoscopy. NOSE scores were compared to SQ, QOL, and disease severity measures. Spearman correlations were used to identify significant associations between measures. Results All patients reported symptomatic nasal obstruction (NOSE score ≥ 30), whereas poor sleep (PSQI ≥ 5) was reported by 82%. The NOSE sleeping subdomain correlated strongly with the PSQI total score, whereas other elements of the NOSE instrument correlated weakly or not at all with this measurement of SQ. Nasal obstruction correlated weakly with disease-specific QOL and had no correlation with the PSQI total. Conclusions Nasal obstruction appears to have a limited association with CRS-specific QOL and CRS-associated decrease in SQ. Further, the NOSE instrument, because it contains a question about sleep, may have overlap with the PSQI as a measure of SQ. The total NOSE score in CRS patients does not appear to be purely a measure of nasal obstruction. Level of Evidence 4 Laryngoscope, 2016

The frontal recess and frontal sinus anatomy can vary from simple to complex. The variations in the anatomy of the frontal recess and frontal sinus are considerable but almost all variations can be classified if the various cell patterns are analyzed. This consensus document was developed to improve the ability of the surgeon to understand these possible variations, plan the surgery, and communicate these complexities when teaching or reporting outcomes. Once the surgeon understands the anatomical pattern of the frontal sinus and recess cells, the extent of surgery can be planned. This document presents a classification of the extent of surgery based on the anatomical classification.

Background Appropriate indications for endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) are currently poorly defined. The lack of clear surgical indications for ESS likely contributes to the large geographic variation in surgical rates and contributes to reduced quality of care. The objective of this study was to define appropriateness criteria for ESS during management of adult patients with uncomplicated CRS. Methods The RAND/UCLA appropriateness methodology was performed. An international, multidisciplinary panel of 10 experts in CRS was formed and completed 2 rounds of a modified Delphi ranking process along with a face-to-face meeting. Results A total of 624 clinical scenarios were ranked, 312 scenarios each for CRS with and CRS without nasal polyps. For adult patients with uncomplicated CRS with nasal polyps, ESS can be appropriately offered when the CT Lund-Mackay score is ≥ 1 and there has been a minimum trial of a topical intranasal corticosteroid plus a short-course of systemic corticosteroid with a post-treatment total SNOT-22 score ≥ 20. For adult patients with uncomplicated CRS without nasal polyps, ESS can be appropriately offered when the CT Lund-Mackay score is ≥ 1 and there has been a minimum trial of a topical intranasal corticosteroid plus either a short-course of a broad spectrum/culture-directed systemic antibiotic or the use of a prolonged course of systemic low-dose anti-inflammatory antibiotic with a post-treatment total SNOT-22 score ≥ 20. Conclusion This study has developed and reported of list of appropriateness criteria to offer ESS as a treatment “option” during management of uncomplicated adult CRS. The extent or technique of ESS was not addressed in this study and will depend on surgeon and patient factors. Furthermore, these criteria are the minimal threshold to make ESS a treatment “option” and do not imply that all patients meeting these criteria require surgery. The decision to perform ESS should be made after an informed patient makes a preference-sensitive decision to proceed with surgery. Applying these appropriateness criteria for ESS may optimize patient selection, reduce the incidence of unwarranted surgery, and assist clinicians in providing high-quality, patient-centered care to patients with CRS

The inferior and middle turbinates are often considered a source of obstruction, usually airway obstruction for the inferior turbinates and sinus obstruction for the middle turbinates. Prior to embarking upon surgical treatment, the surgeon is reminded that these are functional structures. This chapter reviews strategies, techniques, and outcomes of turbinate surgery. Anatomy and physiology are discussed, as well as potential pearls and pitfalls in surgical treatment. Individual techniques are described in stepwise fashion, and the limited knowledge of comparative outcomes with different techniques is explored.

Endoscopic and open microsurgical approaches for pediatric patients are useful for a wide variety of skull base pathologies. A hybrid, cranioendoscopic approach may be beneficial in improving surgical resection for complex lesions. A case of a 13-year-old boy with a large juvenile nasopharyngeal angiofibroma extending through the nasopharynx and pterygopalatine fossa into the maxillary, sphenoid, and cavernous sinuses is demonstrated via an endoscopic, transnasal and frontotemporal, extended middle cranial fossa microsurgical approach. Management of a large pediatric tumor via narrow nasal passages, safe surgical resection around critical neurovascular structures, and complication avoidance is demonstrated.The video can be found here: https://youtu.be/1WqvsOnQCxs.

BACKGROUND The Relative Value Scale Update Committee, commonly known as the RUC, is responsible for defining the value of Current Procedural Terminology (CPT) codes. The RUC process uses survey responses reporting operative times to determine procedure reimbursement, but it is limited by low response rates, small sample sizes, and unclear generalizability of the results. By comparing actual reported intraoperative times to the times determined by the RUC process, in this study we sought to assess the performance of RUC methodology in endoscopic sinus surgery (ESS). METHODS The ESS CPT codes that were reassessed in 2016 using the RUC method were examined in this study. Intraoperative time data for these codes were retrospectively collected from 14 medical facilities, using time stamps in the electronic health record. These actual intraoperative times were compared with the 2016 RUC survey results. RESULTS There were 143 RUC physician survey responses and 446 actual procedure times included in the final analysis. There was significant variability within the RUC survey responses (ie, unilateral anterior ethmoidectomy times varied from 5 to 90 minutes). There was also a significant difference between the RUC survey results and actual intraoperative times (p < 0.001). For example, frontal sinus surgeries showed a particularly poor correlation between actual and RUC times. CONCLUSION The RUC process may not accurately estimate or value actual intraoperative times. Real-world intraoperative times are readily accessible and may be an alternative to survey-based methodology in the future.

Background Calgranulin C (S100A12) is an innate immune peptide at the air–mucosal interface associated with neutrophil involvement, which when overexpressed has been implicated as a biomarker of inflammatory diseases. Decreased epithelial expression of certain innate immune peptides has been reported in chronic rhinosinusitis (CRS). We hypothesized that S100A12 is differentially expressed in the sinonasal mucosa of patients with CRS compared to controls and that S100A12 is a potential biomarker of CRS-specific quality of life (QOL) and disease severity. Methods A prospective observational study was conducted which included 70 patients: 17 controls, 28 having CRS without (CRSsNP), and 25 with (CRSwNP) nasal polyps. The expression of S100A12 and human neutrophil elastase (HNE) was assessed in the anterior ethmoid tissues from all patients using enzyme-linked immunosorbent assay (ELISA) and immunohistochemical (IHC) analyses. Disease-specific QOL (Rhinosinusitis Disability Index) and disease severity (computed tomography [CT] and endoscopy) were evaluated and correlated to the expression levels of S100A12. Results S100A12 and HNE were significantly elevated in patients with CRSsNP compared to normal controls ( P Conclusions S100A12 is differentially expressed in CRS subtypes and is significantly elevated in patients with CRSsNP and associated with CRS-specific disease severity.