Andrew Thamboo

Medical management of allergic fungal rhinosinusitis following endoscopic sinus surgery: an evidence‐based review and recommendations

Allergic fungal rhinosinusitis (AFRS) is a subset of polypoid chronic rhinosinusitis that is characterized by the presence of eosinophilic mucin with fungal hyphae within the sinuses and a Type I hypersensitivity to fungi. The treatment of AFRS usually involves surgery in combination with medical therapies to keep the disease in a dormant state. However, what constitutes an optimal medical regimen is still controversial. Hence, the purpose of this article is to provide an evidence‐based approach for the medical management of AFRS.

Surgical therapy vs continued medical therapy for medically refractory chronic rhinosinusitis: A systematic review and meta-analysis

The currently accepted treatment paradigm of treating chronic rhinosinusitis (CRS) first with appropriate medical therapy (AMT) and then with surgery if patients are refractory to AMT, has been criticized for lack of evidence. The objective of this study was to reassess the literature and establish the highest level of evidence possible regarding further management of CRS patients refractory to AMT.

The safety and efficacy of short-term budesonide delivered via mucosal atomization device for chronic rhinosinusitis without nasal polyposis

Budesonide is a potent corticosteroid commonly prescribed for management of inflammation in chronic rhinosinusitis (CRS). The standard for prescribing budesonide is via impregnated nasal saline irrigation (INSI), although recently the mucosal atomization device (MAD) has emerged as a theoretically superior method of distributing medication into the sinuses. The MAD atomizes medication into small droplets and this is thought to enhance absorption and improve bioavailability. However, no studies have shown whether enhanced absorption and improved bioavailability of budesonide via MAD causes adrenal suppression. The objective of this study is to determine whether budesonide via MAD affects the hypothalamic‐pituitary‐adrenal (HPA) axis.

Endoscopic frontal sinusotomy—Preventing recurrence or a route to revision?†‡

The Messerklinger technique is an endoscopic approach to sinus surgery designed to be minimally invasive and preserve mucosa and therefore physiological function. More recently there have been advocates for more radical endoscopic approaches to the frontal sinus such as the modified Lothrop procedure. This study aims to determine the effectiveness of endoscopic frontal sinusotomy in preventing recurrent frontal sinus disease and the need for any revision frontal sinus surgery.

The effect of head position on the distribution of topical nasal medication using the Mucosal Atomization Device: a cadaver study.

The Mucosal Atomization Device (MAD) distributes medication throughout the paranasal sinuses for patients with chronic rhinosinusitis (CRS). Determining the optimal head position is important to ensure maximal delivery of medication to the sinus cavities. The objective of this work was to determine the effect of the lying‐head‐back (LHB) and head‐down and forward (HDF) position, on the distribution of topical nasal medication via MAD in cadaver specimens.

The Empty Nose Syndrome 6‐Item Questionnaire (ENS6Q): a validated 6‐item questionnaire as a diagnostic aid for empty nose syndrome patients

Empty nose syndrome (ENS) is considered an acquired condition that remains difficult to diagnose objectively. Defining specific symptoms that can be reliably associated with this disorder would be essential to identifying possible ENS patients. We sought to validate an ENS‐specific, 6‐item questionnaire as an adjunct to the standard Sino‐Nasal Outcome Test 22 (SNOT‐22) questionnaire to discriminate patients suspected of having ENS.

Distinguishing computed tomography findings in patients with empty nose syndrome

Given the lack of basic diagnostic criteria for empty nose syndrome (ENS), we sought to define whether consistent radiographic characteristics could be identified to aid in the development of such criteria.

Use of the SNOT-22 and UPSIT to Appropriately Select Pediatric Patients With Cystic Fibrosis Who Should Be Referred to an Otolaryngologist: Cross-sectional Study

IMPORTANCE Sinonasal disease and, specifically, nasal polyps, occur frequently in children with cystic fibrosis (CF). As survival rates have improved, it has become imperative that otolaryngologists become involved in the care of patients with CF to provide appropriate medical and surgical interventions for sinonasal disease. Despite significant variability in the subjective reporting of clinical symptoms, previous work has suggested there may be a relationship between clinical indicators and sinonasal disease in this population. OBJECTIVE To determine whether the 22-item Sino-Nasal Outcome Test (SNOT-22), the University of Pennsylvania Smell Identification Test (UPSIT), and other measures of sinonasal disease could be used to predict the presence of subclinical nasal polyps in children with CF. DESIGN, SETTING, AND PARTICIPANTS This was a cross-sectional study performed from May 2012 through April 2013 at a cystic fibrosis clinic at BC Childrens Hospital in Vancouver, British Columbia, Canada. There were 72 eligible children with CF for this study (with a confirmed diagnosis of CF based on genetic testing; their ages ranged from 6 to 18 years, and they were not actively being treated by an otolaryngologist). Thirty-seven of these patients (23 males, 14 females) consented to participate in this study. Twenty-three declined participation, and 12 could not be contacted. MAIN OUTCOMES AND MEASURES Potential clinical predictors for the presence of subclinical nasal polyps were determined a priori. All 37 recruited participants completed a full study assessment. Nasal endoscopy (the gold standard) was performed to determine the presence of nasal polyps. Potential predictors that were assessed included age, sex, genotype, pancreatic function, SNOT-22 and UPSIT scores, oral culture swab result, and severity of forced expiratory volume in 1 second (FEV(1)). RESULTS A SNOT-22 score of greater than 11 was the only statistically significant predictor of nasal polyps (P = .04). The positive predictive value was 68.1%, the negative predictive value was 66.7%, and the positive likelihood ratio was 1.82. CONCLUSIONS AND RELEVANCE Given that the SNOT-22 is easy to administer and inexpensive, this sinus disease-specific questionnaire seems to be an appropriate tool for routine use by respirologists when assessing patients with CF to help predict subclinical nasal polyps.

Variables associated with olfactory disorders in adults: A U.S. population-based analysis

Objective Olfactory dysfunction is known to have significant social, psychological, and safety implications. Despite increasingly recognized prevalence, potential risk factors for olfactory loss have been arbitrarily documented and knowledge is limited in scale. The aim of this study is to identify potential demographic and exposure variables correlating with olfactory dysfunction. Methods Cross-sectional analysis of the 2011–2012 and 2013–2014 editions of the National Health Examination and Nutrition Survey was performed. The utilized survey reports from a nationally representative sample of about 5000 persons each year located in counties across the United States. There is an interview and physical examination component which includes demographic, socioeconomic, dietary, and health-related questions as well as medical, dental, physiologic measurements, and laboratory tests. 3594 adult respondents from 2011 to 2012 and 3708 respondents from 2013 to 2014 were identified from the above population-based database. The frequency of self-reported disorders as well as performance on odor identification testing was determined in relation to demographic factors, occupational or environmental exposures, and urinary levels of environmental and industrial compounds. Results In both subjective and objective analysis, smell disorders were significantly more common with increasing age. While the non-Hispanic Black and non-Hispanic Asian populations were less likely to report subjective olfactory loss, they, along with Hispanics, performed more poorly on odor identification than Caucasians. Those with limited education had a decreased prevalence of hyposmia. Women outperformed men on smell testing. Those reporting exposure to vapors were more likely to experience olfactory dysfunction, and urinary levels of manganese, 2-Thioxothiazolidine-4-carboxylic acid, and 2-Aminothiazoline-4-carboxylic acid were lower among respondents with subjective smell disturbance. In odor detection, elevated serum levels of lead and urinary levels of 2,4 dichlorophenol were associated with anosmia and hyposmia, respectively. Conclusions This study provides current, population-based data identifying demographic and exposure elements related to smell disturbances in U.S. adults. Age, race, gender, education, exposure to vapors, urinary levels of manganese, 2-Thioxothiazolidine-4-carboxylic acid, 2-Aminothiazoline-4-carboxylic acid, 2,4 dichlorophenol, and serum lead levels were all implicated in smell disturbance. Care should be taken in interpretation due to lack of consistency between subjective and objective measures of olfaction as well as limitations related to population-based data. Prospective trials are indicated to further elucidate these relationships.

Office Procedures in Refractory Chronic Rhinosinusitis

Office procedures in chronic rhinosinusitis (CRS) can be considered before and after medical management, as well as before and after surgical management. This article focuses specifically on refractory CRS, meaning those patients who have failed medical and surgical management already. The options available in the management of refractory CRS depend on the personnel, equipment, and instrumentation available in the office setting; surgeon experience; and patient suitability and tolerability. This article provides readers with possible procedural options that can be done in their clinics with indications, patient selection, potential complications, and postoperative considerations.