American Journal of Rhinology & Allergy最新文献

Objective: Conductive olfactory losses mainly involve obstruction of the olfactory cleft (OC) and diminished OC airflow. This study investigated the association between abnormal nasal structure and OC airflow.

Methods: A systematic search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis to identify studies on the effect of the nasal structure on the OC airflow and olfaction.

Results: A total of 11 studies were included. Nasal vestibule morphological variabilities directly impact the transport of molecules in odorant-laden air to the OC. A greater airflow vortex and a narrower vestibule region intensified the airflow vortex toward the olfactory region. Middle turbinectomy significantly increased the average flux to the OC. The location of the major airflow and airflow velocity maxima shifted towards the OC in patients with septal deviation. The airflow has been redirected into the upper part of the nasal airway in patients with inferior turbinate hypertrophy. For patients with unilateral cleft lip, unilateral nasal airflow on the cleft side has a lower rate and flow. The mean velocity in the posterior OC correlated well with olfaction compared to that in the anterior OC. The nasal polyps (NP) within the middle meatus increased the olfactory airflow but did not enhance the olfaction. NP in the olfactory region or anterior to the olfactory region significantly decreased the olfactory airflow and olfaction. Furthermore, obstruction of the OC did not change the nasal patency. When the OC shape presented with a stenotic slit or lumen structure among patients with conductive olfactory dysfunction without NP, the inspiratory velocity and flow rate within OC were significantly lower than in the healthy control group.

Conclusion: Various nasal structural factors affect patterns of OC airflow and olfaction. Identifying the related airflow-limiting structures may promote the comprehensive evaluation of conductive olfactory losses in patients with olfactory dysfunction.

Background: To reduce recurrence rates of inverted papilloma (IP), some have argued for the use of intraoperative frozen margins; results remain mixed and studies critically lack lengthy surveillance periods.

Objective: We aim to elucidate the impact of prolonged surveillance and intraoperative frozen margins on IP recurrence.

Methods: This is a retrospective analysis of patients who underwent resection of IP at a tertiary care center over a 10-year period from 2008 to 2018 followed by subsequent surveillance. Patient demographics, tumor and operative characteristics, and recurrences were analyzed.

Results: Our analysis includes 199 patients, with 37 recurrences and an average recurrence time of 44.4 months; 57% of patients received intraoperative frozen sections and recurrence rates were similar between those who received frozen sections and those who did not (20.1% vs 15.5%, P = .36). Patients with recurrences within 5 years of surgery were more likely to have received frozen sections than those with recurrences beyond 5 years (P < .01). There was no difference in surgical approach or extent of disease in those who received frozen margins. Patients that received frozen sections were more likely to have multiple sites of attachment (56.5% vs 38.1%, P = .01) and persistent disease following a previous resection at an outside institution (67.0% vs 44.0%, P = .001).

Conclusion: Our average time to recurrence was 44.4 months, significantly longer than surveillance times reported in the literature, indicating that longer periods of surveillance are necessary to capture late recurrences. Our analysis is the first and largest American cohort to look at IP resection in a standardized fashion and find that recurrence rates are similar between patients receiving frozen sections or not.

Background: Sinonasal mucosal melanoma has poor survival despite multimodality treatment. While the impact of immunotherapy (IT) on metastatic cutaneous melanoma is well-defined, there are relatively little data on sinonasal mucosal melanoma.

Objective: We sought to define immunotherapy outcomes in patients with sinonasal mucosal melanoma.

Methods: A retrospective cohort study evaluated patients treated with IT during their overall treatment strategy for SNMM. Patient demographics, treatment, and survival outcomes were recorded.

Results: 52 patients had IT treatment for SNMM from 2000 to 2022, with an average age of 69.1 ± 11.9 years. The most common treatment was surgery with radiation and IT (n = 26, 50%). Most regimens consisted of a combination of Nivolumab and Ipilimumab (n = 17, 32.7%) or pembrolizumab (n = 14, 26.9%). 44.2% of patients experienced reported complications. Overall survival at 1-, 2-, and 5 years was 86.9%, 74.1%, and 39.1%, respectively.

Conclusion: Approximately half of patients will have a local response following immunotherapy, but it is rare to have improvement at metastatic locations. Further research within our group will assess optimal timing and markers that are predictive of response.

Background: Epistaxis is one of the most common and debilitating symptoms of hereditary hemorrhagic telangiectasia (HHT), significantly impacting patients' quality of life. While various medical and surgical interventions exist for managing epistaxis in patients with HHT, patients with moderate to severe epistaxis are high health-care utilizers who frequently need surgical treatment.

Objective: To compare the efficacy, complications, and patient-reported outcomes for common surgical interventions utilized in treating epistaxis in patients with HHT.

Methods: Studies were identified in PubMed, Embase, Scopus, Redalyc, and LILACS databases and uploaded to Covidence. A systematic review following PRISMA guidelines was conducted on studies evaluating outcomes in adults with HHT with moderate to severe epistaxis who had undergone surgical interventions. We compared the respective outcomes for pre-operative and post-operative epistaxis severity/intensity, need for further interventions or transfusions, estimated blood loss, length of surgery, complications, and patient satisfaction.

Results: Twenty studies with a total of 546 patients were included. The most common surgeries studied were nasal closure and laser photocoagulation. Seven studies recorded the change in epistaxis severity score and observed a significant reduction postoperatively (3.91, [95% CI 2.73-5.09]). Eleven studies found a decrease in the number of transfusions and a rise in hemoglobin levels post-operatively. Common complications reported were partial dehiscence of a nasal closure, septal perforation, and continued bleeding requiring re-operation. Most patients report improved quality of life and satisfaction with surgical intervention.

Conclusion: Surgery can significantly reduce the severity of epistaxis in patients with HHT and improve quality of life. Further studies should focus on head-to-head comparisons of procedures and standardization of outcome measures.

Background: The success rate of chronic rhinitis surgery varies depending on the patients' factor and surgical method. While outcomes for nasal obstruction differ, the association between preoperative severity of other rhinitis symptoms, such as rhinorrhea, sneezing, and nasal itching, measured via the reflective total nasal symptom score (rTNSS) remains unevaluated.

Objective: To evaluate the association between the response rate to surgical treatment of chronic rhinitis and preoperative severity.

Methods: A retrospective cohort study was conducted among adult patients with chronic rhinitis symptoms refractory to medication and nasal spray for over 6 months and received radiofrequency ablation of inferior turbinates with posterior nasal nerve neurolysis. The primary endpoint was the change from baseline in 24-h rTNSS and nasal obstruction symptom evaluation (NOSE) scores. Postoperative surgery response rate, rTNSS score change, and score improvement ratios were also evaluated.

Results: A total of 183 patients (110 males, 60.1%) were included in this study. After 3-month follow-up, the preoperative rTNSS was 6.51 ± 2.74 change to 1.70 ± 1.43, and the NOSE score was 56.48 ± 19.90 change to 4.56 ± 7.74. Both scores and all sub-scores showed significant differences when comparing preoperative, 1-month, and 3-month results (P < 0.05-0.001). The response rate by rTNSS for whole cohort was 78.14 ± 41.44% and 93.99 ± 23.83% at 1- and 3-month follow-up. Subgroup analyses were performed according to individual rTNSS scores and 2 in 1 score groups (ie, 1-2, 3-4, etc) and their relationship to the surgery outcomes. Both preoperative individual score and score groups were significantly associated with all post-operation outcomes (P = 0.022 to <0.001) in linear regression analysis.

Conclusion: Patients with more severe preoperative rhinitis symptoms are associated with better response rate, post-operation symptom score changes, and score improvement ratio.

Background: Thymic stromal lymphopoietin (TSLP) plays an important role in mediating the type-2-inflammatory response. This study examined how TSLP and interleukin (IL)-4 levels in patients with chronic rhinosinusitis with nasal polyps (CRSwNP) correlated with clinical and postoperative outcomes.

Methods: Solid-phase sandwich ELISA was used to analyze TSLP and IL-4 levels in mucus (n = 47), plasma (n = 17), polyp (n = 30), inferior (n = 25), and middle (n = 26) turbinate tissue collected during functional endoscopic sinus surgery (FESS) in CRSwNP patients (n = 76) and controls (n = 11). Inclusion criteria includes patients with medical treatment refractory CRSwNP confirmed by endoscopy or maxillofacial CT. Exclusion criteria include history of immunodeficiency, coagulation disorders, fungal sinusitis, or cystic fibrosis. Levels of TSLP and IL-4 were correlated with SNOT-22, UPSIT, and fractional exhaled nitric oxide (FeNO) using MannWhitney U two-tailed test and linear regression with Spearman correlation coefficient test.

Results: TSLP is elevated in the inferior turbinates (effect size = 2.695, p = 0.0007) of CRSwNP patients compared to controls. IL-4 is expressed at elevated levels in the inferior (effect size = 3.092, p < 0.0001) and middle turbinates (effect size = 2.041, p = 0.019) compared to controls. Mucus TSLP (r = 0.4013, p = 0.0153) and IL-4 (r = 0.6138, p < 0.0001) positively correlate with preoperative FeNO levels. Lower TSLP in the inferior (r = -0.5179, p = 0.0231) and middle turbinates (r = -0.5075, p = 0.0224) and lower IL-4 in the inferior turbinates (r = -0.5205, p = 0.0223) correlate with a greater improvement in SNOT-22 post-FESS.

Conclusion: TSLP and IL-4 are elevated in patients with CRSwNP and correlated with increased preoperative FeNO levels and decreased sinonasal quality of life benefit after FESS. Expression of TSLP and IL-4 may play a role in guiding postoperative expectations in patients with treatment refractory CRSwNP.

Background: Patients with aspirin-exacerbated respiratory disease (AERD) have difficult-to-treat asthma and chronic rhinosinusitis with nasal polyps (CRSwNP) and often require treatment with biologic therapy for asthma or CRSwNP. Healthcare utilization in patients with AERD has not been well described since the advent of respiratory biologics.

Objective: To determine real-world healthcare utilization and quality of life among patients with AERD and to understand the impact of dupilumab, a monoclonal antibody targeting the interleukin 4 receptor, on patient-reported health outcomes and healthcare utilization.

Methods: We conducted a longitudinal survey study of 98 patients with AERD recruited from the Brigham and Women's Hospital AERD registry. Patients completed online questionnaires describing their medication history, healthcare utilization, and quality of life every 3 months for 2 years.

Results: At the end of 24 months, participants who were on dupilumab at the start of the study and those who started dupilumab had a significant reduction in the number of reported poor health days in the preceding month compared to patients not on dupilumab (P < .001 and P < .01, respectively). Participants on dupilumab and those who started dupilumab also had significantly lower overall sinonasal outcome test-22 and asthma control test scores compared to those not on dupilumab over 24 months (P < .05 for both groups).

Conclusion: Dupilumab therapy significantly improves health-related quality of life in patients with AERD, specifically as it pertains to patient assessment of days of overall poor health and quality of life related to sinonasal and asthma symptoms.

Background: Acute invasive fungal rhinosinusitis (AIFR) is a life-threatening disease mainly affecting immunocompromised patients. Early detection is therefore key to improving patient survival. To date, there are still no standard clinical criteria for AIFR diagnosis.

Objective: This study develops a predictive model that utilizes clinical presentation and computed tomography (CT) findings to diagnose AIFR.

Methods: A retrospective cohort study was conducted on patients with high risk for AIFR at King Chulalongkorn Memorial Hospital over the past 15 years (2008-2022). We constructed several multivariate logistic regression models for AIFR diagnosis based on different subsets of variables from 3 categories: signs/symptoms, endoscopy, and CT imaging.

Results: There were 67 AIFR-positive patients and 68 AIFR-negative patients. Combining variables from 3 categories, a 6-variable model (fever, visual loss, mucosal discoloration, crusting, mucosal loss of contrast, retroantral fat stranding) achieved the highest area under the receiver operating characteristic curve of 0.8900 (74.63% sensitivity, 89.71% specificity).

Conclusions: We proposed predictive models for AIFR diagnosis in high-risk patients using clinical variables. The models can be used to guide the decision for further management such as biopsy or surgical intervention.

Background: Computed tomography (CT) plays a crucial role in assessing chronic rhinosinusitis, but lacks objective quantifiable indicators.

Objective: This study aimed to use deep learning for automated sinus segmentation to generate distinct quantitative scores and explore their correlations with disease-specific quality of life.

Methods: From July 2021 to August 2022, 445 CT data were collected from 2 medical centers. A deep learning model based on nnU-Net was trained for automatic sinus segmentation and internally validated using 300 cases. The remaining 145 cases were split into an external testing set (74 cases) and an independent testing set (71 cases). Two quantitative scores, the quantitative Lund-MacKay score and the quantitative opacification score (QOS), were derived from the segmentation results. The quantitative scores' efficacy was assessed by comparing them with the Lund-MacKay score (LMS), the 22-item Sinonasal Outcome Test score (SNOT-22), and other clinical variables through correlation analyses. Furthermore, the relationship between quantitative scores and postoperative quality of life improvement was explored using single-factor logistic regression.

Result: The segmentation model achieved average Dice similarity coefficients of 0.993, 0.978, 0.958, and 0.871 for the training, validation, external testing, and independent testing sets, respectively. Both quantitative scores significantly correlated with the LMS (rho = 0.87 and rho = 0.70, P < .001). Neither score correlated with the total SNOT-22 score, although the modified QOS showed significant correlations with the nasal and sleep subdomains (rho = 0.26 and rho = 0.27, P < .05). No significant association was found between quantitative score and postoperative improvement in quality of life.

Conclusion: Deep learning enables the automated segmentation of sinuses on CT scans, producing quantitative scores of sinus opacification. These automatic quantitative scores may serve as tools for chronic rhinosinusitis assessment.

Purpose: Fractional nasal exhaled NO (FnNO), fractional exhaled NO (FeNO) and lung function tests were performed in children with moderate-to-severe persistent allergic rhinitis (AR) to investigate the significance of the above indices in the assessment and diagnosis of children with AR.

Methods: A total of 135 children with persistent AR were selected and divided into moderate-to-severe and mild groups; serum total immunoglobulin E (IgE), peripheral blood eosinophil counts (EOS), FnNO, FeNO, and lung function tests were performed.

Results: Children in the moderate-to-severe group had increased levels of FnNO and FeNO and decreased levels of forced expiratory flow at 75% of forced vital capacity as a percentage of the predicted value (FEF75%) and maximum mid-term expiratory flow as a percentage of the predicted value (MMEF%) . IgE in children with AR was positively correlated with FeNO and FnNO and negatively correlated with FEF75% . EOS was positively correlated with FnNO. FeNO was negatively correlated with FEF75% and forced expiratory flow at 50% of forced vital capacity as a percentage of the predicted value (FEF50%). FnNO was negatively correlated with FEF75%, FEF50%, and MMEF%.

Conclusion: FnNO, FeNO, and pulmonary function tests may help assess disease severity and level of disease control in children with persistent AR.