Miglani, Amar

Abstract Objective To describe and illustrate septal perforation shape through the documentation and analysis of length and height measurements. A secondary objective is to correlate perforation size to surgical and nonsurgical etiologies. Stuy Design Retrospective case series. Setting Tertiary academic medical center. Methods Length and height of consecutively treated perforations over a 3‐year period were measured directly or through computed tomography. Mean differences in length and height measurements were compared and regression analysis used to determine perforation shape and the effect of etiology on perforation size. Perforations were classified by length into small (1‐5 mm), medium (6‐15 mm), and large (>15 mm) and correlated to shape and etiology. Results One hundred twenty‐four patients (mean age 50.4 years, 60.5% female) met study inclusion criteria. Height was less than length in 93% of perforations 5 mm or greater in length. Mean perforation height was significantly less than length for medium and large perforations ( P < .001). Mean length and height measurements of nonsurgical perforations were greater than those for surgical perforations ( P < .001). Conclusion Height is less than length in over 90% of septal perforations. Most perforations assume an elliptical shape as they enlarge. Accurate measurement and presentation of length and height is relevant information to perforation management decisions and for the evaluation of treatment outcomes.

BackgroundNasal septal perforations (NSP) can have a heterogeneous appearance on endoscopic examination with varying degrees of crusting, inflammatory change, and associated septal deviation. The clinical applicability of these findings as contributors to patient symptoms may be enhanced by use of a standardized assessment.MethodsVideo nasal endoscopy recordings were obtained from 40 patients with NSP. Five raters with varied levels of training ranging from a senior resident to an experienced septal perforation surgeon independently reviewed the videos for the following exam findings: crusting, scarring, granulation tissue, septal deviation, and edema. Scoring for each item was reported on a 3‐point (0–2) scale, and each reviewer repeated scoring at a 14‐day interval. Interrater and intrarater agreement were calculated using Fleiss kappa for each item and the total scores. Additionally, endoscopy scores were correlated with patient‐reported NOSE‐Perf symptom scores.ResultsInterrater agreement for the overall instrument was in the “fair‐to‐moderate” range with the following interrater agreement for each item: crusting (0.458–0.575), scarring (0.286–0.308), granulation (0.403–0.406), deviation (0.487–0.494), and edema (0.253–0.406). Intrarater agreement was generally “substantial” for individual items as well as the overall instrument (0.688). The NSP endoscopy scores were moderately correlated with NOSE‐Perf scores (r = 0.44, p = 0.008).ConclusionsAn endoscopic evaluation of NSP comprising five exam findings has acceptable interrater and intrarater reliability and correlates with patient‐reported outcomes. NSP endoscopy may be applied to future clinical studies for characterization of NSP and assessment of treatment outcomes.Level of Evidence3 Laryngoscope, 134:3049–3053, 2024

Key Points Combined endoscopic sinus surgery and nasal septal perforation repair is technically feasible. NOSE‐Perf is a recently developed patient‐reported outcome measure for nasal septal perforation. The decision to perform combined ESS and NSP repair should be made on a case‐by‐case basis.

AbstractObjectiveTo determine if simultaneous administration of acoustic vibration and oscillating expiratory pressure affects the severity of facial pain among patients with complaint of “sinus headache”.MethodsThis is a prospective single‐arm observational study performed at a tertiary care medical center. Subjects with complaint of sinus headache without evidence of chronic rhinosinusitis on exam or computed tomography participated in a clinical study applying simultaneous acoustic vibrations and positive expiratory pressure to the nasal cavity twice daily over 4 weeks. Efficacy was assessed using three validated pain metrics—pain visual analog scale (VAS), brief pain inventory‐short form (BPI‐SF), and McGill pain questionnaire‐short form (MPQ‐SF). Device safety and patient satisfaction were also assessed using questionnaires.ResultsTwenty‐nine patients (mean age 49 years, 55% female) completed the study without any major adverse events. At the 4 week follow‐up, facial pain VAS improved from mean ± SD of 59.6 ± 15.7 to 34.6 ± 21.7 (p < .001), BPI mean pain (mean ± standard deviation) improved from 4.4 ± 2.0 to 2.9 ± 1.9 (p = .007), and MPQ‐SF total improved from 12.2 ± 6.5 to 6.5 ± 5.2 (p < .001) with approximately 70% of patients achieving a minimal clinically important difference (MCID) across all metrics. Additionally, pain VAS was assessed 5 min after a single use at baseline with significant improvement (p < .001). Eighty‐six percent of subjects would both use device again and recommend it to others.ConclusionsSimultaneous administration of acoustic vibration and oscillating expiratory pressure appears to be a safe treatment for sinus headaches in patients without objective evidence of chronic sinusitis. Results from this initial study are promising with regard to efficacy in treatment of sinus headaches but will require further study.Level of evidence2c.

Background Mometasone-eluting poly-L-lactide-coglycolide (MPLG) is available commercially for frontal sinus ostium (FSO) stenting. An alternative chitosan polymer-based drug delivery microsponge is also available at a lower cost per unit. Objective To compare the outcomes of MPLG stents versus triamcinolone-impregnated chitosan polymer (TICP) microsponge in frontal sinus surgery. Methods Patients who underwent endoscopic sinus surgery from December 2018 to February 2022 were reviewed to identify those with the intraoperative placement of TICP microsponge or MPLG stent in the FSO. FSO patency was evaluated by endoscopy at follow-up. Twenty-two-item sinonasal outcome test (SNOT-22) was also recorded, and complications were noted. Results A total of 68 subjects and 96 FSOs were treated. TICP was first used in August 2021 and MPLG in December 2018. MPLG placement in a Draf 3 cavity was excluded since TICP had not been used during Draf 3 procedure. Both cohorts (TICP 20 subjects, 35 FSOs; MPLG 26 subjects, 39 FSOs) had similar clinical characteristics. At a mean total follow-up of 249.2 days for TICP and 490.4 days for MPLG, FSO patency was 82.9% and 87.1%, respectively ( P = .265). At an equivalent follow-up of 130.6 days in TICP and 154.0 days in MPLG, patency was 94.3% and 89.7%, respectively ( P = .475). Both groups showed significant reductions in SNOT-22 ( P < .001). MPLG demonstrated crusting within the FSO at 1 month (none in TICP). Conclusion FSO patency for both stents was similar, although TICP had significantly lower costs per unit. Additional comparative trials may be helpful for guiding clinicians on the appropriate clinical situations for the use of these devices.

Background: Nasal septal perforation repair is commonly attempted utilizing bilateral nasal mucosal flaps supported with an interposition graft. Objectives: To compare the failure rates for bilateral flap repairs utilizing four different autologous interposition grafts. Methods: This is a retrospective review of a single surgeon's bilateral flap perforation repairs supported with an autologous interposition graft. Study inclusion over the 18-year review period required at least one examination 1 month after surgery. Repair failure rates were calculated and compared for each graft type, and logistic regression was performed for multivariate analysis. Results: For the 356 study patients, median (range) age was 51 years (14–81) and 63.0% were women. Mean (range) perforation length was 13.9 mm (1–45). Median (range) at last follow-up was 11.2 months (1–192). Graft types used (percentage of patients and failure rate) were temporalis fascia (58.7/4.4), septal cartilage (23.3/7.3), auricular perichondrium (13.8/4.1), and septal bone (4.2/6.7) ( p > 0.05). Conclusion: There was no significant difference in bilateral mucosal flap perforation repair failure rate when either a temporalis fascia, septal cartilage, auricular perichondrium, or septal bone interposition graft was used.

AbstractObjectiveTo determine whether septal perforations have an effect on nasal swell body (NSB) size.Study DesignRetrospective cohort study.SettingTwo tertiary academic medical centers.MethodsComputed tomography maxillofacial scans of 126 patients with septal perforation and 140 control patients from November 2010 to December 2020 were evaluated. Perforation etiology was determined. Measurements included perforation length and height and swell body width, height, and length. Swell body volume was calculated.ResultsThe width and volume of the NSB are significantly smaller in perforation patients when compared to controls. The swell body is significantly smaller and thinner in perforations exceeding 14 mm in height compared to small perforations. Perforation etiology groupings into prior septal surgery, septal trauma, septal inflammatory, and mucosal vasoconstriction categories all demonstrated decreased swell body volume and width compared to controls. Inflammatory etiology had the greatest decrease in swell body size. The hemi‐swell body on the contralateral side of a septal deviation is significantly thicker than the ipsilateral side.ConclusionThe NSB is smaller in patients with septal perforation regardless of perforation size or etiology.

ObjectiveRNA sequencing (transcriptomics) is used to study biological pathways. However, the yield of data depends on comparing well‐characterized cohorts. We compared tissue eosinophilia versus nasal polyp (NP) status as the metric to characterize transcriptomic mechanisms at play in eosinophilic and non‐eosinophilic chronic rhinosinusitis (CRS) versus controls.MethodsRNA sequencing was conducted on sinonasal tissue samples of CRS and controls. Analyses were conducted based on polyp status [with nasal polyps (CRSwNP) and without nasal polyps (CRSsNP)] as well as tissue eosinophil levels per high power field (eos/hpf)[non‐eosinophilic (<10 eos/hpf, neCRS) or eosinophilic (≥10 eos/hpf, eCRS)]. The yield of differentially expressed genes (DEGs) and biological pathways through Ingenuity Pathway Analysis (IPA) were compared.ResultsCRS tissue differed from controls by 736 statistically significant DEGs. Both NP status and tissue eosinophilia were effective in differentiating CRS from controls and into two distinct subgroups. Statistically significant DEGs identified when comparing CRS by NP status were 60, whereas 110 DEGs were identified using eosinophil cutoff ≥10 and <10 eos/hpf. Additionally, heatmaps showed greater homogeneity within each CRS subgroup when analyzed by tissue eosinophilia versus NP status. On IPA, the IL‐17 signaling pathway was significantly different only by tissue eosinophilia status, not NP status, being higher in CRS <10 eos/hpf.ConclusionTissue eosinophilia is superior to an analysis by NP status for the study of CRS transcriptome by RNA sequencing in identifying DEGs. Classification of CRS samples by eosinophil counts agnostic of NP status may offer advantageous insights into CRS pathogenetic mechanisms.Level of Evidence3 Laryngoscope, 133:2480–2489, 2023