Hyperbaric Oxygen Therapy for Sudden Sensorineural Hearing Loss after Failure from Oral and Intratympanic Corticosteroid

Systemic and intratympanic steroids are most widely used for treating idiopathic sudden sensorineural hearing loss. Other treatments include vasodilator, immunosuppressant and antiviral medication. However, only 61% of patients achieve full recovery, and controversies about the standard treatment still exist. In this case report, we present a patient with idiopathic sudden sensorineural hearing loss who failed to respond to systemic and intratympanic steroid treatments but subsequently recovered after undergoing hyperbaric oxygen therapy

European Position Paper on Rhinosinusitis and Nasal Polyps 2020

The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 is the update of similar evidence based position papers published in 2005 and 2007 and 2012. The core objective of the EPOS2020 guideline is to provide revised, up-to-date and clear evidence-based recommendations and integrated care pathways in ARS and CRS. EPOS2020 provides an update on the literature published and studies undertaken in the eight years since the EPOS2012 position paper was published and addresses areas not extensively covered in EPOS2012 such as paediatric CRS and sinus surgery. EPOS2020 also involves new stakeholders, including pharmacists and patients, and addresses new target users who have become more involved in the management and treatment of rhinosinusitis since the publication of the last EPOS document, including pharmacists, nurses, specialised care givers and indeed patients themselves, who employ increasing self-management of their condition using over the counter treatments. The document provides suggestions for future research in this area and offers updated guidance for definitions and outcome measurements in research in different settings. EPOS2020 contains chapters on definitions and classification where we have defined a large number of terms and indicated preferred terms. A new classification of CRS into primary and secondary CRS and further division into localized and diffuse disease, based on anatomic distribution is proposed. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, allergic rhinitis, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. All available evidence for the management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is systematically reviewed and integrated care pathways based on the evidence are proposed. Despite considerable increases in the amount of quality publications in recent years, a large number of practical clinical questions remain. It was agreed that the best way to address these was to conduct a Delphi exercise. The results have been integrated into the respective sections. Last but not least, advice for patients and pharmacists and a new list of research needs are included.Peer reviewe

Corticosteroid nasal irrigations after endoscopic sinus surgery for recalcitrant chronic rhinosinusitis

"A thesis submitted to fulfil the requirements for the degree of Doctor of Philosophy".Thesis by publication."May 2013"Includes bibliographical references.1. Background -- 2. Structured histopathology profiling of chronic rhinosinusitis in routine practice -- 3. Eosinophilic rhinosinusitis is not a disease of ostiomeatal occlusion -- 4. Osteitic bone: a surrogate marker of eosinophilia in chronic rhinosinusitis -- 5. Correlation of the Kennedy Osteitis Score to clinico-histologic features of chronic rhinosinusitis -- 6. Topical steroid for chronic rhinosinusitis without polyps -- 7. Topical steroid for nasal polyps -- 8. Sinus surgery and delivery method influence the effectiveness of topical corticosteroid for chronic rhinosinusitis; systematic review and meta-analysis -- 9. Corticosteroid nasal irrigations after endoscopic sinus surgery in the management of chronic rhinosinusitis -- 10. Thesis discussion and conclusion -- Appendix.Chronic rhinosinusitis (CRS) is a heterogeneous disease with multiple pathogenic factors and various inflammatory mechanisms. Although high eosinophil content in the sinus tissue has been acknowledged as a marker of recalcitrant CRS, eosinophilic chronic rhinosinusitis (ECRS) is traditionally diagnosed by its phenotypes other than structured histopathology profiling. Osteitis is another marker associated with recalcitrant inflammation. However, the pathogenesis of osteitis in patients without previous sinus surgery is poorly understood. Patients with ECRS and patients with osteitis have higher disease severity and poorer treatment outcomes. Both observed changes are thought to be features of disordered inflammation. Currently, topical steroid is the first line drug recommended for treating CRS. Although having strong anti-inflammatory effects, topical steroid sprays provide poor sinus delivery. Published randomized controlled trials on the efficacy of topical steroids in CRS use either nasal delivery (nasal drop, nasal spray) or sinus delivery (sinus catheter, sinus irrigation) in patients with or without sinus surgery. This heterogeneity influences topical drug delivery and distribution. This thesis examines the basis of diagnosis, characterisation of the inflammatory process, influence of surgery and device in drug delivery and proposes a revised treatment of CRS with postoperative corticosteroid nasal irrigation which combines the therapeutic effects of sinus surgery and sinus delivery of corticosteroid for an inflammatory condition. In this treatment paradigm, the purpose of sinus surgery is to create access for topical therapies rather than a fundamental concept of relieving ostiomeatal obstruction. Even for the challenging subgroups of ECRS and patients with osteitis, had favourable outcomes and even greater improvement than the non ECRS subgroup. When CRS is managed as an inflammatory condition with local mucosal inflammation controlled with effectively delivered pharmaceutical solutions, therapy is greatly optimized compared to traditional regimes.Mode of access: World wide web1 online resource (507 pages) illustration

Sphenoid Sinus Cholesteatoma—Complications and Skull Base Osteomyelitis: Case Report and Review of Literature

Introduction: Cholesteatoma of the paranasal sinuses is uncommon. Its clinical characteristics are an expanding growth of the affected paranasal sinuses consisting of keratinizing squamous epithelium with bony wall destruction. Among involved paranasal sinuses, sphenoid sinus cholesteatoma is the least common. Case presentation: An 82-year-old female diabetic patient presented with subacute onset of fever after experiencing chronic progressive headaches for more than 20 years. Nasal endoscopy found purulent discharge from left sphenoethmoidal recess. Computed tomography (CT) scan of the paranasal sinus showed soft tissue lesions that totally filled the left sphenoid sinus with posterior and inferior wall destruction. There was no evidence of connection to the left mastoid cavity. Management and outcome: Left sphenoidotomy was performed. Histopathology revealed cholesteatoma. Two months after surgery, she became worse and CT showed extensive skull base destruction. The patient underwent bilateral sphenoidectomy and craniotomy with surgical debridement of osteomyelitis of the skull base. She received long-term intravenous ertapenam and sitafloxacin for treating drug-resistant Klebsiella infection. The osteomyelitis could not be controlled, and she died. Discussion: Progressive headache can be caused by an uncommon disease such as sphenoid sinus cholesteatoma, which is a surgical condition. Complicating osteomyelitis of the skull base requires extensive debridement surgery and should be anticipated

Reshaping the Management of Allergic Rhinitis in Primary Care: Lessons from the COVID-19 Pandemic

The COVID-19 pandemic presented unique challenges to the delivery of healthcare for patients with allergic rhinitis (AR) following its disruption and impact on the healthcare system with profound implications. Reliance on self-care for AR symptom management was substantial during the pandemic with many patients encouraged to only seek in-person medical care when necessary. The advantage of digital technology becomes apparent when patients and healthcare providers had to change and adapt their method of interaction from the regular physical face-to-face consultation to telehealth and mobile health in the provision of care. Despite the pandemic and the ever-evolving post pandemic situation, optimal management of AR remains paramount for both patients and healthcare professionals. A reshaping of the delivery of care is essential to accomplish this goal. In this paper, we present what we have learned about AR management during the COVID-19 pandemic, the role of digital technology in revolutionizing AR healthcare, screening assessment in the identification and differentiation of common upper respiratory conditions, and a framework to facilitate the management of AR in primary care

Validity of European position paper on rhinosinusitis disease control assessment and modifications in chronic rhinosinusitis

Objectives: To develop a chronic rhinosinusitis (CRS) disease control staging system that predicts patient and physician opinion. This involved exploring the predictive capacity of the proposed European Position Paper on Rhinosinusitis (EPOS) 2012 staging system and other potential scoring systems based on patient symptoms and objective criteria. Study Design: Prospective study. Setting: Tertiary hospitals. Subjects and Methods: Adults CRS patients undergoing sinus surgery were prospectively enrolled from a tertiary clinic. The Sino-Nasal Outcome Test 22, endoscopy score, and systemic medication were recorded at 6 and 12 months. A physician and patient report of their condition as either ''controlled,''''partly controlled,'' or ''uncontrolled'' was also recorded. Ordinal regression was used for modeling a staging system. The EPOS criteria and various combinations were assessed. Kappa agreements between the staging systems and patient/physician reports were analyzed. Results: One hundred six patients were assessed. Nasal obstruction (P = .02), endoscopic mucosal inflammation (P< .001), and thick and/or purulent discharge (P = .01) associated with progress reports. A modified staging system of Nasal Obstruction, Systemic medication used, and Endoscopic inflammation (NOSE) was selected on predictive strengths. The EPOS and NOSE had significant agreement with physician's (k = 0.29, P<.01, and k = 0.45, P <.01) and patient's report (k = 0.18, P = .01, and k = 0.32, P<.01). Conclusions: The disease control assessment by EPOS has slight agreement with patients and a physician. A simpler NOSE system using nasal obstruction, mucosa, and discharge is proposed.8 page(s

Eosinophilic rhinosinusitis is not a disease of ostiomeatal occlusion

Objectives/Hypothesis: Ostiomeatal complex (OMC) occlusion may play a role in the pathogenesis of some chronic rhinosinusitis (CRS) subgroups, but its role in diffuse mucosal inflammation is strongly debated. The association between radiological OMC occlusion and its draining sinuses in patients with eosinophilic rhinosinusitis (ECRS) compared to non-ECRS is investigated. Methods: Patients with CRS who underwent endoscopic sinus surgery were investigated. Preoperative computed tomography scans were evaluated. Structured histopathology reporting was performed. The study group was patients with high tissue eosinophil >10/high power fields (HPF), and the control group was patients with low tissue eosinophil ≤ 10/HPF. The radiological relationship of OMC occlusion to the draining sinuses was analyzed in each group. Results: Seventy patients with a mean age of 49.7 ± 14.1 years were analyzed. Forty-one (58.6%) patients had high tissue eosinophil >10/HPF. All patients with ECRS had maxillary disease, and there were 36.2% without OMC occlusion. There was no association of OMC occlusion to either the anterior ethmoid (ECRS: odds ratio [OR], 1.84; 95% confidence interval [CI], 0.24-14.14; P = .55; non-ECRS: OR, 1.57; 95% CI, 0.34-7.33; P = .56) or frontal sinuses (ECRS: OR, 0.67; 95% CI, 0.12-3.82; P = .65; non-ECRS: OR, 1.58; 95% CI, 0.45-5.54; P = .47). For patients with non-ECRS, maxillary sinus diseases was present in 96.2% of those with OMC occlusion and 50% of those without (OR, 25.0; 95% CI, 2.77-226.08; P < .001). Conclusions: OMC occlusion is not associated with draining sinuses for patients with ECRS. Simple surgical interventions directed at the OMC are unlikely to be of benefit to this CRS subgroup.5 page(s

Correlation of the Kennedy Osteitis Score to clinico-histologic features of chronic rhinosinusitis

Background: Osteitis is a feature of chronic rhinosinusitis (CRS) and often associated with recalcitrant disease. Radiological characteristics of osteitic sinus changes are commonly reported in practice but the clinical and pathologic significance is poorly defined. The objective of this study was to correlate the Kennedy Osteitis Score (KOS) to clinico-histologic features of CRS. Methods: A cross-sectional study of CRS patients undergoing sinus surgery was conducted. Osteitis was scored radiologically using the KOS. Associations between osteitis and histopathology, symptoms, 22-item Sino-Nasal Outcomes Test (SNOT-22), endoscopy, computed tomography (CT) mucosal score, and seromarkers were assessed. Interobserver correlation coefficient was performed. Additionally, the KOS was correlated to an alternate Global Osteitis Score. Results: A total of 88 patients were assessed (45.5% female, age 50.3 ± 13.6 years); 45 (51.1%) patients had osteitis. Patients with KOS >0, had greater endoscopy score (6.1 ± 2.9 vs 4.4 ± 3.6, p = 0.03) and CT score (14.0 ± 6.0 vs 10.1 ± 5.7, p 0.3 x 109/L (4.0 [2.0-7.0] vs 1.0 [0.0-4.0], p < 0.01). Importantly, this was also true for those without prior surgery. The interobserver correlation coefficient was good (R = 0.86, p < .001). There was a significant correlation between the KOS and the Global Osteitis Score (R = 0.93, p < 0.001). Conclusion: The KOS is a simple, easy, and reproducible scale in assessing osteitic bones in patients with CRS and can predict measures of severity in eosinophilic rhinosinusitis.7 page(s

Is orbital floor a reliable and useful surgical landmark in endoscopic endonasal surgery?: a systematic review

Abstract Background The orbital floor is considered as an important intraoperative reference point in endoscopic sinonasal surgery. The aim of this review is to evaluate its reliability and usefulness as a surgical landmark in endoscopic endonasal surgery. Methods A literature search was performed on electronic databases, namely PUBMED. The following keywords were used either individually or in combination: orbital floor; maxillary sinus roof; endoscopic skull base surgery; endoscopic sinus surgery. Studies that used orbital floor as a landmark for endoscopic endonasal surgery were included in the analysis. In addition, relevant articles were identified from the references of articles that had been retrieved. The search was conducted over a period of 6 months between 1st June 2017 and 16th December 2017. Results One thousand seven hundred forty-three articles were retrieved from the electronic databases. Only 5 articles that met the review criteria were selected. Five studies of the orbital floor (or the maxillary sinus roof) were reviewed, one was a cadaveric study while another 4 were computed tomographic study of the paranasal sinuses. All studies were of level III evidence and consists of a total number of 948 nostrils. All studies showed the orbital floor was below the anterior skull base irrespective of the populations. The orbital floor serves as a guide for safe entry into posterior ethmoids and sphenoid sinus. Conclusions The orbital floor is a reliable and useful surgical landmark in endoscopic endonasal surgery. In revision cases or advanced disease, the normal landmarks can be distorted or absent and the orbital floor serves as a reference point for surgeons to avoid any unintentional injury to the skull base, the internal carotid artery and other critical structures

The Outside-in approach to the modified endoscopic lothrop procedure

Objectives/Hypothesis: Drilling in modified endoscopic Lothrop procedure (MELP) is traditionally described as commencing from the frontal recess (FR). This is challenging when the FR is involved by tumor, inflammatory disease, or scarring. The outside-in MELP, where the limits of the sinusotomy are first defined and the FR is addressed last, is described. Study Design: Case-control study. Methods: Patients undergoing MELP, using the standard or outside-in approach, for inflammatory disease or endoscopic skull base surgery were assessed. Data were collected on demographics, disease characteristics, and FR involvement. Operative time was calculated from intraoperative video recording. Time points recor ded were times to frontal sinus and recess connected for outside-in MELP and completion of Lothrop cavity for both groups. Perioperative complications (infection, skin breach or contusion, surgical emphysema, orbital bleeding, cerebrospinal fluid leak, and intracranial complications) were recorded. Results: Thirty patients (67% female) with a mean age ± standard deviation of 56.0 ± 10.8 years underwent MELP (24 outside-in, six standard). Time for Lothrop completion was shorter for outside-in MELP (30.60 ± 14.10 minutes vs. 69.66 ± 64.52 minutes, P =.002). Among outside-in MELP, mean time to frontal sinus floor discovery was 8.41 ± 6.29 minutes, to recess connected 26.50 ± 12.45 minutes, and were similar regardless of pathology. The time for Lothrop cavity completion was shorter for tumor cases (24.63 ± 6.49 minutes) than for chronic rhinosinusitis without polyps (35.87 ± 20.18 minutes) and chronic rhinosinusitis with polyps (34.62 ± 11.56 minutes) (P =.05). One patient had skin edema. No other complications were recorded. Conclusions: The outside-in MELP is technically feasible and safe. Its advantage is a wide approach to the frontal sinus with development of the Lothrop cavity en route resulting in short predictable operative times. Defining the limits of the dissection early provides a robust and efficient approach.9 page(s