Citations

ABSTRACTBackground/AimEosinophilic granulomatosis with polyangiitis (EGPA) is a multisystemic disease associated with nasal polyposis. Multiple biologics are used for managing EGPA, including some approved for nasal polyps (NP). This study investigated real‐world biologic prescription patterns for EGPA and their impact on NP and endoscopic sinus surgery (ESS) use.MethodsEGPA patients with NP treated with a biologic at any Mayo Clinic site (January 2010 to January 2024) were identified by querying the unified electronic medical record. Patterns of biologic therapy, clinical course, impact on NP, and performance of ESS were studied.ResultsEighty patients were identified. Overall, 71 of 80 (88.75%) patients underwent ESS, with 62 of 80 (77.5%) undergoing 131 ESS procedures prior to biologic therapy. ESS for recalcitrant NP (47 episodes) was performed on 38 of 80 (47.5%) patients on biologics. Biologic monotherapy was used in 90% (72) of patients; mepolizumab (81.9%) was the most common, followed by rituximab (23.6%), benralizumab (18.1%), and dupilumab (12.5%). Switching of biologics was observed in 28 of 80 patients. Concurrent dual‐biologic therapy was used in eight (10%) patients. For patients on single‐agent biologic therapy, ESS was performed on 52.5% of patients on mepolizumab, 23.5% on rituximab, 42.8% on benralizumab, and 22.2% on dupilumab.ConclusionsMultidisciplinary multi‐modality treatment with biologics and ESS appeared to be the mainstay of controlling NP in EGPA. Mepolizumab was the most frequently used biologic. Dual biologic therapy was necessary in 10% of patients. Overall, 71 of 80 (88.75%) patients had ESS, with almost half the study population (47.5%) undergoing ESS after initiating biologic treatment.

AbstractThe study objective was to compare the length of stay (LOS) and the proportion of one-night admissions before and after the implementation of an endocrine monitoring protocol following endoscopic transsphenoidal surgery (ETSS) for pituitary adenoma.Patients who underwent transsphenoidal pituitary adenoma resection between July 1, 2018, and September 9, 2022, were identified, and divided into two cohorts before and after the implementation of the monitoring protocol. The overall LOS and number of nights of admission were recorded. Readmission within 30 days after surgery was also recorded. The number of outpatient laboratory tests performed and the time to the first test were also noted.Thirty patients were identified in the preprotocol group and 60 in the postprotocol group. The average admission length in the preprotocol group was significantly longer than the average admission length in the postprotocol group (2.4 vs. 1.7 days, p = 0.004). The percentage of one-night admissions increased from 13 to 57% (p < 0.001). There were no significant differences in readmission rates between the two groups (p = 0.681). The number of laboratory encounters increased from a mean of 1.38 to 2.40 (p = 0.030), while the time to the first test decreased from a mean of 3.43 to 2.36 days (p = 0.049).Patients admitted after ETSS for pituitary adenoma had shorter hospital stay and greater proportion of one-night admission with the implementation of an endocrine monitoring protocol. The all-cause readmission rate was not statistically different between the two groups. Through aggressive outpatient laboratory monitoring, one-night admission for ETSS may be feasible.

Although technical causes of endoscopic sinus surgery (ESS) failure have long been reported, we were curious about the quality of contemporary sinus surgery. The electronic health database of Mayo Clinic, Arizona was scrutinized to identify adult patients with diffuse chronic rhinosinusitis (CRS) who underwent revision ESS between January 2019 and September 2023 with a history of bilateral full-house ESS. Anatomical features on preoperative radiology and intraoperative endoscopy were cataloged: residual uncinate tissue, maxillary antrostomy with a non-incorporated natural os, residual ethmoidal septations (three septations > 3 mm), and inadequate sphenoid osteotomy (os size < 6 mm). Sixty-nine subjects were identified. A deviated nasal septum was present in 53.6%. Residual uncinate tissue was noted in 50.7% of patients associated with missed natural maxillary os in 39.13% of antrostomies. An inadequate os diameter was noted in 63.8% of sphenoidotomies. Significant residual septations were seen in posterior ethmoidal cells in 66.7% and anterior ethmoidal cells in 62.3% of patients. Residual frontoethmoidal cells were noted in 72.4% of patients. Although the extent of ESS must be individualized, a high prevalence of features reflecting suboptimal surgery that could limit the success of ESS was identified. These findings merit further consideration for focused training during residency and continuous professional development activities.

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.

Abstract Background Sinonasal neoplasms, whether benign and malignant, pose a significant challenge to clinicians and represent a model area for multidisciplinary collaboration in order to optimize patient care. The International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors (ICSNT) aims to summarize the best available evidence and presents 48 thematic and histopathology‐based topics spanning the field. Methods In accordance with prior International Consensus Statement on Allergy and Rhinology documents, ICSNT assigned each topic as an Evidence‐Based Review with Recommendations, Evidence‐Based Review, and Literature Review based on the level of evidence. An international group of multidisciplinary author teams were assembled for the topic reviews using the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses format, and completed sections underwent a thorough and iterative consensus‐building process. The final document underwent rigorous synthesis and review prior to publication. Results The ICSNT document consists of four major sections: general principles, benign neoplasms and lesions, malignant neoplasms, and quality of life and surveillance. It covers 48 conceptual and/or histopathology‐based topics relevant to sinonasal neoplasms and masses. Topics with a high level of evidence provided specific recommendations, while other areas summarized the current state of evidence. A final section highlights research opportunities and future directions, contributing to advancing knowledge and community intervention. Conclusion As an embodiment of the multidisciplinary and collaborative model of care in sinonasal neoplasms and masses, ICSNT was designed as a comprehensive, international, and multidisciplinary collaborative endeavor. Its primary objective is to summarize the existing evidence in the field of sinonasal neoplasms and masses.

Background Epigenetics studies mechanisms such as DNA methylation, histone modifications, non-coding RNAs, and alternative polyadenylation that can modify gene activity without changing the underlying DNA nucleotide base-pair structure. Because these changes are reversible, they have potential in developing novel therapeutics. Currently, seven pharmaceutical agents targeting epigenetic changes are FDA approved and commercially available for treatment of certain cancers. However, studies investigating epigenetics in chronic rhinosinusitis (CRS) have not been undertaken previously in the United States. Objectives The goal of this study was to investigate sinonasal DNA methylation patterns in CRS versus controls, to discern environmentally-induced epigenetic changes impacting CRS subjects. Methods and Results Ethmoidal samples from CRS and inferior turbinate mucosal tissue samples from controls without CRS were studied. DNA methylation was studied by Reduced Representation Bisulfite Sequencing. RADMeth® biostatistical package was used to identify differentially methylated regions (DMRs) between CRS and controls. Ingenuity Pathway analysis of DMRs was performed to identify top upstream regulators and canonical pathways. Ninety-three samples from 64 CRS subjects (36 CRSwNP; 28 CRSsNP) and 29 controls were studied. CRS and control samples differed in 13 662 CpGs sites and 1381 DMRs. Top upstream regulators identified included: 1. CRS versus controls: TGFB1, TNF, TP53, DGCR8, and beta-estradiol. 2. CRSwNP versus controls: TGFB1, CTNNB1, lipopolysaccharide, ID2, and TCF7L2. 3. CRSsNP versus controls: MYOD1, acetone, ID2, ST8SIA4, and LEPR. Conclusions Differential patterns of methylation were identified between controls and CRS, CRSwNP, and CRSsNP. Epigenetic, environmentally-induced changes related to novel, inflammatory, immunologic, and remodeling pathways appear to affect epithelial integrity, cell proliferation, homeostasis, vascular permeability, and other yet uncharacterized pathways and genes.