Citations

ObjectivesDelayed anesthesia recovery following endoscopic sinus surgery (ESS) can be an indicator of immediate complications and negatively impact healthcare efficiency. This study aims to examine clinical factors with a focus on improving clinical practice.MethodsMedical records of patients undergoing ESS under general anesthesia from 2014 to 2018 were reviewed. Based on the interquartile range of anesthesia recovery for the cohort, patients in the upper quartile were categorized as “prolonged” and the lowest three quartiles as “goal” recovery. Patient and surgical characteristics were investigated.ResultsAnalyzing 416 patients who underwent ESS, the median anesthesia recovery time was 48 [35–66] minutes. Prolonged recovery was associated with higher body mass index (odds ratio 1.50 [95% confidence interval 1.03–2.18] per 10 kg/m2, P = .03) and surgical duration (1.37 [1.10–1.72] per hour, P < .01). Inversely, goal recovery was associated with preoperative acetaminophen (0.61 [0.38–0.98], P = .04) and intraoperative remifentanil (0.55 [0.32–0.93], P = .03). Patients with prolonged recovery had higher rates of severe pain (33 (31.7%) vs. 25 (8.0%), P < .01), respiratory depression (7 [6.7] vs. 2 [0.6], P < .01), oversedation (39 [37.5] vs. 39 [12.5], P < .01), and the need for rescue opioids (52 [50] vs. 71 [22.8], P < .01). In addition to reduced postanesthesia recovery time, patients who were administered preemptive acetaminophen had lower rates of severe pain (OR 0.55 [0.31–0.98], P = .04) and nausea and vomiting (0.39 [0.17–0.87], P = .02).ConclusionOur findings substantiate the use of acetaminophen and remifentanil in ESS, facilitating anesthesia recovery. Broadly consideration of preemptive acetaminophen could further increase postoperative comfort in ESS.Level of Evidence4 – Retrospective. Laryngoscope, 131:E815–E820, 2021

AbstractObjectivesThe purpose of this article is to provide a state‐of‐the‐art review of the literature and summarize the latest publications on medical and surgical treatment of cystic fibrosis (CF) chronic rhinosinusitis (CRS), with an emphasis on describing recent advancements in cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapies.MethodsA comprehensive literature review was conducted utilizing the PubMed database with search phrases detailed within the body of the article. Abstracts were reviewed to include publications detailing medical, surgical, and CFTR modulating therapies for CF CRS. Findings from studies not previously reviewed and publications regarding CFTR modulators were emphasized.ResultsNo clear guidelines for treatment of CF CRS are available. Nasal saline rinses, topical steroids, topical antibiotics, and topical dornase alfa are reported medical therapies. Ivacaftor has some sinonasal symptomatic benefit. A new triple therapy CFTR modulator, elexacaftor/tezacaftor/ivacaftor, is capable of treating 90% of patients with CF and has shown the greatest FEV1 improvement of any CFTR modulator yet. There is no clear consensus on surgical indications or technique, though aggressive surgery in recalcitrant disease has shown some symptomatic benefit. Endoscopic sinus surgery after lung transplantation may benefit some patients in whom the sinuses serve as a reservoir for recurrent pulmonary infections by decreasing rates of bronchiolitis obliterans syndrome and improving 5 year survival.ConclusionAs lifespan increases for patients with CF, further investigation into medical therapy, CFTR modulator sinonasal outcomes, and surgical technique and outcomes for CF CRS is needed.Level of Evidence5.

ObjectiveThis study aims to describe presenting characteristics of patients diagnosed with non‐invasive chronic rhinosinusitis (CRS) following liver or kidney transplant and determine factors associated with disease‐related complications, selection of endoscopic sinus surgery (ESS), and disease resolution in this population.Study designRetrospective chart review.SettingAn academic tertiary care center (Mayo Clinic, Rochester, Minnesota).Subjects and methodsLiver and kidney transplant recipients evaluated by Mayo Clinic otolaryngologists for CRS between 1998 and 2018 were identified. Univariate and multivariate logistic regression analyses were used to determine patient factors and treatment modalities associated with developing complications, selection of ESS, and disease resolution.ResultsFifty‐seven patients met inclusion criteria. No patients developed intraorbital or intracranial complications of their CRS. Multivariate modeling demonstrated that the presence of polyps (P = 0.036) was associated with undergoing ESS within one year of presentation. A higher Lund–Mackay (LM) computed tomography score (P = 0.023) and older age (P = 0.018) were significantly associated with decreased disease resolution. No other factors were significantly associated with the use of endoscopic sinus surgery within one year of otolaryngology presentation or resolution of CRS in this cohort.ConclusionThe risk of developing CRS‐related intraorbital or intracranial complications in this immunecompromised patient cohort may be lower than originally thought. For liver‐ and kidney‐recipients stable on immunosuppressive medication for many years, prognostic factors for CRS may mirror those for immunocompetent patients.

Background: Grand rounds and named lectureships are forums in academic medicine for sharing research, scholarly achievements, and clinical expertise. An invitation to speak at grand rounds is regarded as an honor and is part of the pathway to academic promotion. We describe gender representation relative to the national academic medical workforce among invited speakers at departmental grand rounds and annual named lectures at a large academic medical center. Materials and Methods: Lists of external speakers for grand rounds from 2015 through 2017 were obtained from 18 departments and for annual named lectures from 2007 to 2017 from 7 departments. Results: Of the 783 invited speakers to the 25 speaker series, there were 178 women (22.7%). The proportion of women speakers for departmental grand rounds ranged from 0% to 59.3%; representation of women speakers was lower than representation in their specialty in 14 of the 18 departments and significantly lower in 4 of the 18 departments. In four departments, there was a higher proportion of women than available in the specialty-specific academic medicine workforce. The proportion of women who spoke at annual named lectures was significantly lower in two of seven lecture series and ranged from 0% to 21.2%. Three departments had no women speakers. Conclusions: The underrepresentation of women as speakers is a potential target to improve gender representation and role modeling and provide equitable opportunity for academic advancement. Solutions may include formal diversity and inclusion training, intentional overrepresentation of invited female speakers, and inclusion of women on grand rounds planning committees.

BackgroundIn this study we aim to describe presenting characteristics and identify prognostic factors for disease resolution in patients with chronic rhinosinusitis (CRS) in the setting of eosinophilic granulomatosis with polyangiitis (EGPA).MethodsPatients evaluated at a tertiary care center with diagnoses of EGPA and CRS were identified. Descriptive statistics were obtained. Univariate analysis was used to search for prognostic factors associated with higher Lund‐Mackay score at presentation and disease resolution.ResultsForty‐four patients were included with a mean age of 52.7 (standard deviation, 14) years. Twenty‐one patients (47.7%) were female, all had a diagnosis of asthma, and 36 (83.7%) had eosinophils >10%. Common presenting symptoms for CRS included nasal discharge (87.9%) followed by nasal congestion (83.9%) and facial pain and pressure (83.8%). Medical management of CRS included systemic corticosteroids (93.2%) and systemic antibiotics (75%). Surgical intervention occurred in 29 patients (67%). Nine patients (20.5%) had resolution of sinus symptoms, including 4 with imaging confirmation. Fourteen patients (31.8%) had continued CRS, but with improved symptoms, whereas 9 patients (20.5%) had continued CRS with no improvement in symptoms. Eleven patients (25%) were lost to follow‐up and 4 (9.1%) died. Univariate analysis did not show antineutrophil cytoplasmic antibody positivity, presence of peripheral eosinophilia, gender, age, or absence of systemic therapy to be predictive of higher Lund‐Mackay score at presentation or predictive of disease resolution.ConclusionCRS in patients with EGPA is often refractory to medical and surgical management. Treatment of these patients should occur in a multidisciplinary setting.

Objective Yellow nail syndrome (YNS) is characterized by the triad of thickened yellow nails, primary lymphedema, and respiratory manifestations including bronchiectasis, chronic cough, pleural effusions, and sinusitis. The purpose of this study is to describe the manifestations of chronic rhinosinusitis (CRS) in patients with YNS and the comorbid manifestations. Methods A retrospective review of patients with YNS with CRS from January 1, 1998 to January 1, 2018 was conducted. Their symptoms, comorbidities, and labs were reviewed. The patient’s sinus computed tomography (CT) scans were then scored using the Lund–Mackay (LM) scoring system. Result Thirty-six patients met the inclusion criteria. The average LM score was 10.2 ± 0.5 (mean ± SD). Sinus involvement included “frothy” dependent sinus secretions in 32 of 36 subjects. The most common location of sinus involvement was the maxillary sinuses (85%), then posterior ethmoid (81%), anterior ethmoid (76%), sphenoid (74%), and frontal sinuses (54%). Comorbid chronic cough (86%), bronchiectasis (65%), lymphedema (39%), and pleural effusion (19%) were also identified. Three patients (8%) had immunodeficiencies. Conclusion This is the largest series describing the sinus manifestations of CRS in patients with YNS. Sinus CT scans showed frothy dependent secretions in the maxillary sinuses and posterior ethmoid sinuses most commonly. YNS patients with sinusitis more commonly presented with chronic cough or bronchiectasis than with pleural effusions or lymphedema. Otolaryngologists should consider the possibility of YNS in patients with CRS, chronic cough, yellow or thickened nail, and CT findings of frothy, dependent sinus secretions.

BackgroundLymphatic dysfunction is hypothesized to be an underlying factor in the pathophysiology of yellow nail syndrome (YNS) (yellow nails, lymphedema, pleural effusions, and frequently chronic rhinosinusitis [CRS]). It is unclear why some YNS patients develop CRS. We quantified lymphatic and total vasculature of sinonasal mucosa in YNS patients and compared it to controls from CRS patients with (CRSwNP) or without polyps (CRSsNP).MethodsImmunohistochemistry was performed on archival sinonasal mucosal samples from 5 patients with YNS and 14 controls with antibodies against podoplanin and CD31, markers of lymphatics. Morphometric assessment was performed on digital images using ImageJ software.ResultsIn YNS, the number of lymphatics/mm2 ranged from 7 to 18/mm2 (controls: 6 to 43/mm2, p = 0.343), with a mean perimeter between 92 and 201 µm (controls: 42 to 280 µm, p = 0.482). Total vasculature density was higher than lymphatics, ranging between 189 and 1159 vessels/mm2, average 669 (controls: 139 to 1467/mm2, average 503, p = 0.257) with smaller average perimeter, 40 to 117 µm, mean 64.8 µm (controls: 42 to 92 µm, mean 65.3 µm, p = 0.965). Lymphatics constituted only a small fragment of the total vasculature, ranging from 1.15% to 4.76%, average 2.34% (controls: 0.81% to 10.58%, average 4.88%, p = 0.156). CRSwNP patients had significantly higher lymphatic density (p = 0.011) and ratio of lymphatics to total vasculature (p = 0.045) than patients with YNS or CRSsNP.ConclusionThis is the first histological analysis of sinus mucosa in patients with YNS. Vascular type, density, size, and distribution in the sinonasal mucosa of YNS patients are not statistically significantly different from those of the CRSsNP group. Lymphatic density and ratio to total vasculature is higher in CRSwNP patients.

Background In the discipline of rhinology and endoscopic skull base surgery (ESBS), 3-dimensional (3D) printing has found meaningful application in areas including preoperative surgical planning as well as in surgical education. However, its scope of use may be limited due to the perception among surgeons that there exists a prohibitively high initial investment in resources and time to acquire the requisite technical expertise. Nevertheless, given the ever decreasing cost of advancing technology coupled with the need to understand the complex spatial relationships of the paranasal sinuses and skull base, the use of 3D printing in rhinology and ESBS is poised to blossom. Objective Help the reader identify current or potential future uses of 3D printing technology relevant to their rhinologic clinical or educational practice. Methods A review of published literature relating to 3D printing in rhinology and ESBS was performed. Results Results were reviewed and organized into 5 overarching categories including an overview of the 3D printing process as well as applications of 3D printing including (1) surgical planning, (2) custom prosthetics and implants, (3) patient education, and (4) surgical teaching and assessment. Conclusion In the discipline of rhinology and ESBS, 3D printing finds use in the areas of presurgical planning, patient education, prosthesis creation, and trainee education. As this technology moves forward, these products will be more broadly available to providers in the clinical and educational setting. The possible applications are vast and have great potential to positively impact surgical training, patient satisfaction, and most importantly, patient outcomes.

ObjectiveTo examine the impact of 2‐dimensional (2D) illustrations and 3‐dimensonal (3D)–printed anatomic models of the frontal sinuses according to the International Frontal Sinus Anatomy Classification in the education of otolaryngology and radiology residents.Study DesignA crossover study design with half of the study participants randomized to the 2D illustration intervention first and the other half randomized to the 3D‐printed model first.SettingRegularly scheduled resident didactic lectures at a tertiary care center.Subjects and MethodsForty‐one otolaryngology and radiology residents were assessed with pre‐ and postintervention questionnaires that included subjective and objective methods of assessment.ResultsOverall, there was a statistically significant improvement in total number of answers correct and in confidence score between the pre‐ and postintervention assessments (P <. 0001). The primary outcome of order of intervention (ie, 2D → 3D vs 3D → 2D) did not result in statistically significant differences in postevaluation scores. In regard to the secondary outcome of learner preference for educational modality, radiology residents favored the 2D illustrations to understand anatomic relationships, while otolaryngology residents preferred the 3D model to be more helpful in surgical planning (P =. 0075).ConclusionThere is no difference between 2D‐illustrated and 3D‐printed International Frontal Sinus Anatomy Classification anatomic models in overall educational outcome, despite the preference of learners. Together, these models can be used as helpful tools in frontal sinus education for otolaryngology and radiology trainees.