Soler, Zachary M.

Abstract Background The literature regarding clinical olfaction, olfactory loss, and olfactory dysfunction has expanded rapidly over the past two decades, with an exponential rise in the past year. There is substantial variability in the quality of this literature and a need to consolidate and critically review the evidence. It is with that aim that we have gathered experts from around the world to produce this International Consensus on Allergy and Rhinology: Olfaction (ICAR:O). Methods Using previously described methodology, specific topics were developed relating to olfaction. Each topic was assigned a literature review, evidence‐based review, or evidence‐based review with recommendations format as dictated by available evidence and scope within the ICAR:O document. Following iterative reviews of each topic, the ICAR:O document was integrated and reviewed by all authors for final consensus. Results The ICAR:O document reviews nearly 100 separate topics within the realm of olfaction, including diagnosis, epidemiology, disease burden, diagnosis, testing, etiology, treatment, and associated pathologies. Conclusion This critical review of the existing clinical olfaction literature provides much needed insight and clarity into the evaluation, diagnosis, and treatment of patients with olfactory dysfunction, while also clearly delineating gaps in our knowledge and evidence base that we should investigate further.

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.

BackgroundQuality improvement (QI) in the management of chronic rhinosinusitis (CRS) is garnering increasing attention. Defining frameworks and metrics to assess the quality of key components in CRS management could assist in reducing unwarranted practice variation and increase high‐quality care.MethodsA panel of the American Rhinologic Society (ARS) QI committee reviewed the literature to determine important presurgical components of CRS care that warrant QI. The evidence was organized into 4 categories: (1) diagnosis, (2) medical management, (3) appropriate patient selection for surgery, and (4) patient‐centered discussion. The combination of these categories was used to develop a framework termed the CRS Appropriate Presurgical Algorithm (CAPA).ResultsPrior to offering surgery for CRS, the best available evidence support the following quality metrics: (1) a guideline‐based diagnosis should be confirmed; (2) appropriate medical management, including a minimum of topical corticosteroid therapy and saline irrigations, should have been attempted (assuming patient tolerance); (3) a computed tomography (CT) scan should be obtained (to confirm the presence of sinus inflammation and for surgical planning); and (4) a patient‐centered discussion regarding treatment options for refractory CRS (ie, alternative medical therapies vs surgery vs observation) while focusing on risks and benefits, the need for long‐term medical compliance, and understanding of patient preferences and expectations.ConclusionDefining metrics that assess key components to CRS care prior to offering surgery has the potential to further improve upon an already successful treatment paradigm, reduce unwarranted practice variation, and to ensure that patients are receiving a similar level of high‐quality care.

BackgroundImproving the quality of healthcare is a complex and resource intensive process. To optimize the allocation of scarce resources, quality improvement (QI) should focus on high‐value diseases that will produce the largest improvement in health system performance. Given the breadth and multidisciplinary nature of sinonasal disease management, the purpose of this study was to transparently develop a prioritized list of sinonasal diseases for QI from the perspective of the specialty of rhinology and the American Rhinologic Society (ARS).MethodsThe RAND modified Delphi methodology was used to rank the priority of nine sinonasal disease categories from 1 (lowest priority) to 9 (highest priority). Two rounds of ranking along with a teleconference meeting was performed by a panel of 9 experts from the ARS Quality Improvement Committee.ResultsThe final QI‐prioritized list of sinonasal diseases are as follows: chronic rhinosinusitis (CRS) (mean score = 8.9), recurrent acute rhinosinusitis (RARS) (mean score = 7.9), sinonasal neoplasms (mean score = 7.0), anatomic nasal obstruction (mean score = 5.9), refractory epistaxis (mean score = 5.2), complicated acute rhinosinusitis (mean score = 5.2), chronic nonallergic rhinitis (mean score = 4.4), orbital disease (mean score = 4.3), uncomplicated acute rhinosinusitis (mean score = 4.1), and allergy/allergic rhinitis (mean score = 3.7).ConclusionThe three most important disease categories for QI from the perspective of the specialty of rhinology were CRS, RARS, and sinonasal neoplasms. Future studies need to define and validate quality metrics for each of these important disease categories in order to facilitate appropriate measurement and improvement initiatives.

BackgroundMeasuring quality outcomes is an important prerequisite to improve quality of care. Rhinosinusitis represents a high value target to improve quality of care because it has a high prevalence of disease, large economic burden, and large practice variation. In this study we review the current state of quality measurement for management of both acute (ARS) and chronic rhinosinusitis (CRS).MethodsThe major national quality metric repositories and clearinghouses were queried. Additional searches included the American Academy of Otolaryngology–Head and Neck Surgery database, PubMed, and Google to attempt to capture any additional quality metrics.ResultsSeven quality metrics for ARS and 4 quality metrics for CRS were identified. ARS metrics focused on appropriateness of diagnosis (n = 1), antibiotic prescribing (n = 4), and radiologic imaging (n = 2). CRS quality metrics focused on appropriateness of diagnosis (n = 1), radiologic imaging (n = 1), and measurement of patient quality of life (n = 2). The Physician Quality Reporting System (PQRS) currently tracks 3 ARS quality metrics and 1 CRS quality metric. There are no outcome‐based rhinosinusitis quality metrics and no metrics that assess domains of safety, patient‐centeredness, and timeliness of care.ConclusionsThe current status of quality measurement for rhinosinusitis has focused primarily on the quality domain of efficiency and process measures for ARS. More work is needed to develop, validate, and track outcome‐based quality metrics along with CRS‐specific metrics. Although there has been excellent work done to improve quality measurement for rhinosinusitis, there remain major gaps and challenges that need to be considered during the development of future metrics.

BackgroundThe impact of failed cerebrospinal fluid leak (CSF) leak repair in endoscopic skull base surgery has not been adequately studied.MethodsIn this investigation we reviewed patients who had undergone endoscopic skull base surgery between 2002 and 2014 at 7 international centers. Demographic variables, comorbidities, tumor characteristics, and repair techniques were evaluated to determine association with successful repair of CSF leak. Postoperative complications and length of stay were compared among groups.ResultsData were collected on 2097 patients who were divided into 3 groups: (1) those with no intraoperative leak (n = 1533); (2) those with successful repair of their intraoperative leak (n = 452); and (3) those with failed repair (n = 112). Compared with successful repair, failed repair was associated with an increased risk of intracranial infection (odds ratio [OR], 5.6; 95% confidence interval [CI], 5.3‐13.15), pneumocephalus (OR, 16; 95% CI, 5.8‐44.4), 30‐day readmission (OR, 8.4; 95% CI, 5.3‐13.5), reoperation (OR, 115.4; 95% CI, 56.3‐236.8), and prolonged hospital stay (14.9 vs 7.0 days, p < 0.01). Outcomes in patients who had successful repairs of intraoperative leaks were similar to those who never had leakage. Intraoperative use of pedicled nasoseptal flaps was associated with successful repair (OR, 0.60; 95% CI, 0.34‐0.92).ConclusionIntraoperative CSF leaks are a frequent and expected occurrence during endoscopic skull base surgery. Failed CSF leak repair has a significant impact on patient outcomes, with increased rates of postoperative pneumocephalus, intracranial infections, reoperation, deep vein thrombosis, readmission, and prolonged hospital stay. Recognition and repair of intraoperative CSF leaks reduces postoperative complications. Use of pedicled nasoseptal flaps improves outcomes in reconstructing defects at higher risk for postoperative leak.

BackgroundIn patients undergoing transnasal endoscopic sellar surgery, an analysis of risk factors and predictors of intraoperative and postoperative cerebrospinal fluid leak (CSF) would provide important prognostic information.MethodsA retrospective review of patients undergoing endoscopic sellar surgery for pituitary adenomas or craniopharyngiomas between 2002 and 2014 at 7 international centers was performed. Demographic, comorbidity, and tumor characteristics were evaluated to determine the associations between intraoperative and postoperative CSF leaks. Correlations between reconstructive and CSF diversion techniques were associated with postoperative CSF leak rates. Odds ratios (OR) were identified using a multivariate logistic regression model.ResultsData were collected on 1108 pituitary adenomas and 53 craniopharyngiomas. Overall, 30.1% of patients had an intraoperative leak and 5.9% had a postoperative leak. Preoperative factors associated with increased intraoperative leaks were mild liver disease, craniopharyngioma, and extension into the anterior cranial fossa. In patients with intraoperative CSF leaks, postoperative leaks occurred in 10.3%, with a higher postoperative leak rate in craniopharyngiomas (20.8% vs 5.1% in pituitary adenomas). Once an intraoperative leak occurred, craniopharyngioma (OR = 4.255, p = 0.010) and higher body mass index (BMI) predicted postoperative leak (OR = 1.055, p = 0.010). In patients with an intraoperative leak, the use of septal flaps reduced the occurrence of postoperative leak (OR = 0.431, p = 0.027). Rigid reconstruction and CSF diversion techniques did not impact postoperative leak rates.ConclusionIntraoperative CSF leaks can occur during endoscopic sellar surgery, especially in larger tumors or craniopharyngiomas. Once an intraoperative leak occurs, risk factors for postoperative leaks include craniopharyngiomas and higher BMI. Use of septal flaps decreases this risk.

BackgroundCommonly used computed tomography (CT) staging systems for chronic rhinosinusitis (CRS) focus on the sinuses and do not quantify disease in the olfactory cleft. The goal of the current study was to determine whether precise measurements of olfactory cleft opacification better correlate with olfaction in patients with CRS.MethodsOlfaction was assessed using the 40‐item Smell Identification Test (SIT‐40) before and after sinus surgery in adult patients. Olfactory cleft opacification was quantified precisely using three‐dimensional (3D), computerized volumetric analysis, as well as via semiquantitative Likert scale estimations at predetermined anatomic sites. Sinus opacification was also quantified using the Lund‐Mackay staging system.ResultsThe overall cohort (n = 199) included 89 (44.7%) patients with CRS with nasal polyposis (CRSwNP) and 110 (55.3%) with CRS without nasal polyposis (CRSsNP). The olfactory cleft opacified volume correlated with objective olfaction as determined by the SIT‐40 (Spearman's rank correlation coefficient [Rs] = −0.461; p < 0.001). The correlation was significantly stronger in the CRSwNP subgroup (Rs = −0.573; p < 0.001), whereas no appreciable correlation was found in the CRSsNP group (Rs = −0.141; p = 0.141). Correlations between sinus‐specific Lund‐Mackay CT scoring and SIT‐40 scores were weaker in the CRSwNP (Rs = −0.377; p < 0.001) subgroup but stronger in the CRSsNP (Rs = −0.225; p = 0.018) group when compared to olfactory cleft correlations. Greater intraclass correlations (ICCs) were found between quantitative volumetric measures of olfactory cleft opacification (ICC = 0.844; p < 0.001) as compared with semiquantitative Likert grading (ICC = 0.627; p < 0.001).ConclusionQuantitative measures of olfactory cleft opacification correlate with objective olfaction, with the strongest correlations seen in patients with nasal polyps.