International Forum of Allergy & Rhinology

Kennedy, David W.

doi: 10.1002/alr.21740pmid: 26869198

Schlosser, Rodney J.; Storck, Kristina; Smith, Timothy L.; Mace, Jess C.; Rudmik, Luke; Shahangian, Arash; Soler, Zachary M.

doi: 10.1002/alr.21651pmid: 26458330

Background After endoscopic sinus surgery (ESS), endoscopy is used to gauge surgical success and clinical outcomes. Prior studies have not examined this topic prospectively using validated outcome metrics across multiple institutions. Methods A multi‐institutional, prospective study of patients with chronic rhinosinusitis (CRS) who underwent ESS completed the 22‐item Sino‐Nasal Outcome Test (SNOT‐22), missed productivity, and medication usage questionnaires 6 months postoperatively. Lund‐Kennedy endoscopy scoring (LKES) was performed with reviewers blinded to patient‐reported data. A control cohort of non‐CRS patients was recruited for comparison. Results Complete data was available on 183 CRS patients and 48 non‐CRS control patients. Approximately 50% of patients achieve perfect or near perfect endoscopy (LKES 0 to 2) after ESS. Postoperative endoscopy correlated with total SNOT‐22 scores (r = 0.278, p < 0.001), with the strongest correlations to rhinologic and extranasal subdomains in the nasal polyp cohort. Improved postoperative endoscopy was associated with decreased antibiotic and oral steroid usage, but had little association with missed productivity. Among patients who achieved near perfect postoperative endoscopy, those with nasal polyps had SNOT‐22 scores that were similar to non‐CRS control patients (mean SNOT‐22 scores 17.7 and 16.3, respectively). However, CRS patients without nasal polyps remained more symptomatic than non‐CRS controls and CRS with nasal polyps patients despite nearly perfect endoscopy (mean SNOT‐22 score 21.6). Conclusion Postoperative endoscopy correlates with SNOT‐22 and medication usage in CRS patients. Polyp patients who achieve near perfect endoscopy have similar symptoms to healthy controls; however, nonpolyp patients with near perfect endoscopy still have rhinologic and extranasal symptoms that are worse than healthy controls.

Benninger, Michael S.; Sindwani, Raj; Holy, Chantal E.; Hopkins, Claire

doi: 10.1002/alr.21652pmid: 26624856

Background The long‐term impact of chronic rhinosinusitis (CRS) with or without allergic rhinitis (AR) on asthma is poorly documented. This study analyzed potential associations of ongoing CRS and AR on asthma. Methods Using the MarketScan™ claims database, patients with CRS and endoscopic sinus surgery (ESS) in 2010 were identified. The date of first sinusitis was determined for all. Patients with asthma at time of first sinusitis diagnosis were excluded. The remaining patients were grouped based on duration of sinusitis, from first diagnosis to surgery—group 1: 1 to <2 years (n = 181); group 2: 2 to <3 years (n = 195); group 3: 3 to <4 years (n = 292); and group 4: 4 to <5 years (n = 536). Yearly incidence and prevalence of newly diagnosed asthmatics was analyzed for all groups. A secondary analysis evaluated the association between AR and asthma. Results Preoperatively, yearly incidence of patients with new asthma diagnoses averaged 4.48% (95% confidence interval (CI), 3.93% to 5.11%) and was significantly greater for patients with AR (5.93%; 95% CI, 4.56% to 7.66%) vs non‐AR (4.15%; 95% CI, 3.56% to 4.82%); p = 0.03. Postoperatively, yearly incidence of asthma was 0.42% (95% CI, 0.18% to 0.88%). No patient had asthma at time of first diagnosis; however, by time of surgery, 9.4%, 12.8%, 18.2%, and 22.40% of patients had been diagnosed with asthma, in groups 1 through 4, respectively. Conclusion AR was a significant risk factor for asthma in patients with CRS. Medically recalcitrant CRS was associated with high incidence rates of asthma, which declined post‐operatively. Patients operated earlier in the disease continuum were therefore at decreased risk of developing asthma.

Topal, Erdem; Celiksoy, Mehmet Halil; Catal, Ferhat; Sinanoglu, Muhammed S.; Karakoc, Habib Tadayyon Einaddin; Sancak, Recep; Ozturk, Fadıl

doi: 10.1002/alr.21648pmid: 26624560

Background The correct use of inhalation devices is essential for successful therapy. We aimed to evaluate the skills in the use of a spacer device with an metered‐dose inhaler (MDI) and factors that influence this skill in asthmatic preschool children's caregivers. Methods The caregivers of 12‐month‐old to 72‐month‐old children were interviewed face‐to‐face and filled out questionnaires. To assess use of the spacer device, we asked the caregivers to verbally describe and demonstrate how they used the device. Results A total of 244 patients were included in the study, and 142 (58.2%) of the caregivers demonstrated every step for using the spacer device. The most frequently mistaken step was waiting for 30 seconds for the second puff after the first puff. When statistically significant and clinically important parameters were analyzed in a logistic regression model, the parameters satisfaction with the spacer device (odds ratio (OR) 29.9; 95% confidence interval (CI), 7.64 to 117.39; p < 0.001), a university graduate (OR 13.5; 95% CI, 3.36 to 54.8; p < 0.001), family monthly income of more than US$1500 (OR 5.3; 95% CI, 2.16 to 13.39; p < 0.001), device training provided by a clinical trainer (OR 12.3; 95% CI, 4.82 to 31.73; p < 0.001), regular follow‐ups (OR 3.6; 95% CI, 1.57 to 8.47; p = 0.003), and the absence of a severe attack during the last year (OR 6.5; 95% CI, 2.64 to 16.43; p < 0.001) were found to be independent factors that affected the correct demonstration of the device. Conclusion The factors most effective in the correct use of the MDI spacer device were satisfaction with the device, training having been given by a clinical trainer on this subject, and the caregiver being a university graduate.

Gunaratne, Dakshika A.; Barham, Henry P.; Christensen, Jenna M.; Bhatia, Daman D.S.; Stamm, Aldo C.; Harvey, Richard J.

doi: 10.1002/alr.21642pmid: 26383187

Background Topical epinephrine is used in endoscopic sinonasal surgery for local vasoconstriction. Potential for cardiovascular complications remains a concern for some due to the possibility of systemic absorption. Topical vs injected epinephrine was examined in a prospective analysis of perioperative cardiovascular effects, and in an audit of cardiovascular complications during endoscopic sinonasal surgery. Methods A prospective cohort study of patients undergoing endoscopic sinonasal surgery was performed. Topical (1:1000) and injected (1:100,000) epinephrine were assessed. Cardiovascular outcomes of heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and electrocardiogram (ECG) changes were examined at baseline and minutely post–topical application (to 10 minutes) and postinjection (to 5 minutes). A retrospective assessment of cardiovascular events associated with a standardized regimen of topical (1:2000) and injected (1:100,000) epinephrine was performed. Results Nineteen patents were assessed (43.42 ± 15.90 years, 47.4% female) in the prospective analysis. Post–topical epinephrine, no significant changes occurred in any cardiovascular parameter. However, following injected epinephrine, changes in HR (59.53 vs 64.11 bpm, p < 0.001), SBP (96.16 vs 102.95 mmHg, p = 0.015), DBP (56.53 vs 60.74 mmHg, p = 0.019), and MAP (69.74 vs 74.81 mmHg, p = 0.002) occurred. On repeated‐measures analysis of variance (ANOVA) all parameters were significantly affected by injection. No ECG abnormalities were seen in either topical or injection phases. The retrospective analysis of 1260 cases identified 2 cases of cardiovascular complications (0.16%), both relating to injected epinephrine. Conclusion Combination topical (1:1000 to 1:2000) and injectable (1:100,000) epinephrine is safe for use in endoscopic sinonasal surgery. Injection resulted in the cardiovascular changes and accounted for the cardiovascular events reported.

Hardy, Elliot T.; Stringer, Scott P.; O'Callaghan, Richard; Arana, Angela; Bierdeman, Michael A.; May, Warren L.

doi: 10.1002/alr.21613pmid: 26290494

Background Saline nasal irrigations (SNI) are an important adjunct in the treatment of rhinosinusitis, and many patients prepare and store these solutions in their homes without an awareness of the potential for contamination. The objectives of this study were to determine if such contamination occurs and the effect of preparation methods on contamination. Methods Stock solutions of various tonicities and pHs were prepared using boiled, bottled, and distilled water (n = 57). The solutions were stored at ambient temperature or refrigerated for 1 week. Each day, 50 mL of the solutions were decanted to simulate transferring the stock solution into an irrigation vector. Cultures of the stock solutions were taken on days 1, 3, and 7. Results Overall contamination rate was 35.1%. The boiled water solutions were more likely to demonstrate bacterial growth (p < 0.001), as were those that were hypotonic (p = 0.046). pH had no significant effect (p = 0.127). Growth occurred as early as 24 hours after solution preparation. Pathogenic species isolated were Staphylococcus aureus, Moraxella sp, Sphingomonas paucimobilis, Acinetobacter junii, Methylobacterium sp, and Brevundimonas diminuta. No bacterial growth occurred in refrigerated solutions (p = 0.008). Conclusion Pathogenic bacterial growth can occur in a short period of time in homemade SNI solutions with routine handling. Solutions should be refrigerated if possible. If solutions are to be stored at ambient temperature, they should be either isotonic or hypertonic and prepared from bottled or distilled water.

Barham, Henry P.; Thornton, Mona A.; Knisely, Anna; Marcells, George N.; Harvey, Richard J.; Sacks, Raymond

doi: 10.1002/alr.21574pmid: 26681570

Background Techniques for inferior turbinate reduction vary from complete turbinectomy to limited cauterization. Surgical methods differ on the degree of tissue reduction and reliance on surgical tissue removal vs tissue ablation. The outcome and morbidity from 3 different turbinate techniques are compared. Methods A randomized double‐blinded study was performed. Patient nasal cavities were randomized to different interventions on each side within the same patient. One group had a combination of submucosal powered turbinate reduction (designated “submucosal”) and submucosal electrocautery (designated “electrocautery”); and the second group had a combination of submucosal powered turbinate reduction (designated “submucosal”) and medial flap turbinoplasty (designated “turbinoplasty”). Patient‐scored nasal obstruction and rhinorrhoea (1 to 5) along with blindly assessed nasal airway patency ratings (1 to 4) was done at 12 and 60 months postoperatively. Pain requiring additional analgesia, crusting, bleeding (needing review), and revision were documented. Results A total of 100 patients were recruited (age 32.79 ± 13.58 years; 39% female). This represented 200 nasal airway surgeries with 100 submucosal procedures, 50 electrocautery and 50 medial flap turbinoplasties. No patients complained of worsening of their obstruction. At 60 months patients in the turbinoplasty group had greater outcomes, with 90.2% having occasional or no decongestant use (Kendall's tau B p < 0.001) compared to electrocautery (15.8%) and submucosal (37.8%). Fewer turbinoplasty patients had a revision procedure (12%, χ2 = 20.08, p < 0.001) compared to electrocautery (54%) and submucosal (40%). Crusting was more common in the electrocautery group (58% vs submucosal 2% and turbinoplasty 0%; χ2 = 92.04; p < 0.001). Conclusion The medial flap turbinoplasty provided consistent, robust results. Long‐term relief of obstructive symptoms without additional risk of complication was observed in the turbinoplasty group.

Schaffer, Frederick M.; Garner, Larry M.; Ebeling, Myla; Adelglass, Jeffrey M.; Hulsey, Thomas C.; Naples, Andrew R.

doi: 10.1002/alr.21653pmid: 26467843

Background We previously reported the safety of a self‐administered subcutaneous immunotherapy (SCIT) protocol. Here we report the results of the retrospective efficacy trial of the United Allergy Service (UAS) self‐administered SCIT protocol. We hypothesized that by utilizing a slow SCIT buildup phase, designed to attain recommended allergen concentrations on a cumulative basis, efficacious outcomes and clinical relevance would be achieved. Methods We enrolled 60 SCIT patients and 56 control patients. The study contrasted baseline and treatment period combined symptom plus medication scores (CSMS) as the primary outcome measure and rhinoconjunctivitis quality of life questionnaire (RQLQ) scores as the secondary study outcome measure. Changes in pollen counts were also examined with regard to effects on these efficacy parameters. Results The treatment group showed significantly improved CSMS (standardized mean difference (SMD): −1.57; 95% confidence interval (CI), −1.97 to −1.18; p < 0.001) and RQLQ (SMD: −0.91; 95% CI, −1.23 to −0.59; p < 0.001). These treatment group outcome measures were respectively improved by 33% and 29% compared to baseline and greater than 40% in comparison to the control group (p < 0.0001). Significant results were also shown when examining these outcome measures with regards to either monotherapy or poly‐allergen SCIT. Furthermore, a comparison to recent meta‐analyses of SCIT studies showed equivalent efficacy and clinical relevance. Assessment of pollen counts during the baseline and treatment periods further corroborated the efficacy of the UAS SCIT protocol. Conclusion These efficacy results, and our previous safety results, show that a carefully designed and implemented self‐administered SCIT protocol is efficacious and safe.

Bleier, Benjamin S.; Castelnuovo, Paolo; Battaglia, Paolo; Turri‐Zanoni, Mario; Dallan, Iacopo; Metson, Ralph; Sedaghat, Ahmad R.; Stefko, S. Tonya; Gardner, Paul A.; Snyderman, Carl H.; Nogueira, Joao Flavio; Ramakrishnan, Vijay R.; Muscatello, Luca; Lenzi, Riccardo;

Carroll, William W.; O'Connell, Brendan P.; Schlosser, Rodney J.; Gudis, David A.; Karnezis, Tom T.; Lawrence, Lauren A.; Soler, Zachary M.; Mulligan, Jennifer K.

doi: 10.1002/alr.21636pmid: 26370180

Background Fibroblasts are implicated in tissue remodeling and recruitment of inflammatory cells in chronic rhinosinusitis (CRS). Populations of fibroblasts remain unquantified in CRS subtypes. The objectives of this study were to measure fibroblast populations in subtypes of CRS, and to investigate the association between fibroblasts and disease severity. Methods Patients undergoing endoscopic sinus surgery (ESS) for CRS were prospectively enrolled from January 2011 to December 2014. Control subjects included patients undergoing endoscopic surgery for non‐inflammatory conditions such as cerebrospinal fluid leak repair or non–hormone‐secreting pituitary tumors. Patients completed 22‐item Sino‐Nasal Outcome Test (SNOT‐22) questionnaires prior to surgery. Blood and tissue biopsies were taken during surgery. Percent of sinonasal fibroblasts was determined via flow cytometry by selecting fibroblast‐specific protein (FSP)‐positive and Mucin 1 (MUC1)‐negative cells. Results A total of 69 patients were enrolled: control (n = 24), CRS without nasal polyps (CRSsNP) (n = 13), CRS with nasal polyps (CRSwNP) (n = 22), and allergic fungal rhinosinusitis (AFRS) (n = 10). Patients with CRSwNP had significantly more fibroblasts than both control (p < 0.001) and CRSsNP (p < 0.01). Patients with AFRS had the most fibroblasts when compared to control (p < 0.0001), CRSsNP (p < 0.0001), and CRSwNP (p < 0.05). Atopy and asthma were not associated with increased fibroblasts in CRSwNP (p = 0.21, p = 0.26, respectively). Increased fibroblasts correlated with subjective disease severity as measured by SNOT‐22 for CRSwNP (p = 0.003) and AFRS (p = 0.048). Conclusion Sinonasal fibroblasts are increased in CRSwNP and AFRS compared to control and CRSsNP. Increased fibroblasts correlated with worse quality of life in CRSwNP and AFRS.