James C. Denneny

Adult chronic rhinosinusitis: definitions, diagnosis, epidemiology, and pathophysiology.

Abstract Chronic rhinosinusitis Chronic rhinosinusitis (CRS) is a term that has been used to describe a number of entities characterized by chronic symptoms of nasal and sinus inflammation or infection. There has been a lack of consensus regarding definitions and treatments because CRS may be a spectrum of diseases with a range of appropriate treatments. The absence of widely accepted definitions for CRS has resulted in a paucity of research directed at understanding its pathophysiology and has hampered efforts to improve treatment. A Task Force was convened by the Sinus and Allergy Health Partnership to summarize much of the current and important information available regarding the prevalence, economic impact, pathophysiology, common inflammatory mediators, and the role of infectious microbes such as bacteria and fungi in CRS. The goal is to establish a standard and usable definition. Through this thorough review of the literature and the expert input from Task Force members, a definition was developed that serves to create a consistent baseline so that many of the currently debated or unanswered questions may be addressed. The new and more-specific Task Force definition is that “ Chronic rhinosinusitis is a group of disorders characterized by inflammation of the mucosa of the nose and paranasal sinuses of at least 12 weeks duration.” Recommended criteria for making the diagnosis of CRS for both clinical care and research were also outlined.

Use of ototopical antibiotics in treating 3 common ear diseases

Prompted by rising rates of antibiotic resistance, lack of standardized treatment regimens, and new treatment alternatives, the American Academy of Otolaryngology-Head and Neck Surgery convened an expert consensus panel to consider recommendations for the responsible use of antibiotics in chronic suppurative otitis media, tympanostomy tube otorrhea, and otitis externa. The Panel concluded that in the absence of systemic infection or serious underlying disease, topical antibiotics alone constitute first-line treatment for most patients with these conditions, finding no evidence that systemic antibiotics alone or in combination with topical preparations improve treatment outcomes compared with topical antibiotics alone. Topical preparations should be selected on the basis of expected bacteriology and informed knowledge of the risk-benefit of each available preparation. The use of nonototoxic preparations in treating acute otitis externa (when the tympanic membrane is perforated or its status is unknown), chronic suppurative otitis media, and tympanostomy tube otorrhea should be considered.

Maxillary sinus puncture and culture in the diagnosis of acute rhinosinusitis: The case for pursuing alternative culture methods

OBJECTIVE: Traditional assessments of the microbial flora associated with acute bacterial rhinosinusitis have relied on maxillary sinus punctures (taps) and culture. These taps are now considered the gold standard for obtaining cultures and are used as the method of identifying bacterial pathogens in antimicrobial trials. Maxillary sinus taps are limited by discomfort to the patients and technical concerns. Because of these factors, the standard of performing taps has limited antibiotic trials and microbial surveillance. Alternatives to maxillary sinus taps have been explored. STUDY DESIGN: We conducted a retrospective, systematic review of the literature from 1950 to 2000 of articles comparing culture techniques in the nose and paranasal sinuses for acute bacterial rhinosinusitis. RESULTS: Nasal cultures have poor correlation to maxillary sinus cultures, whereas there is 60% to 85% concordance between endoscopically guided middle meatal cultures and maxillary sinus cultures. These studies, however, are all limited by small sample sizes and therefore are inadequate to make any concrete recommendations regarding the relative role of endoscopically guided middle meatal cultures as a formal method of pathogen identification in acute bacterial rhinosinusitis. CONCLUSION: A formal prospective study with sufficient sample size to assess the concordance between the microbial flora of the maxillary sinus punctures and middle meatal cultures in acute rhinosinusitis is recommended.

The workforce in otolaryngology-head and neck surgery: moving into the next millennium.

OBJECTIVE: The goal was to examine the current scope of otolaryngologists’ practices, their geographic distribution, and the roles otolaryngologists and other specialists play in caring for patients with otolaryngic and related conditions of the head and neck. STUDY DESIGN: A large national survey and administrative claims databases were examined to develop practice profiles and compile a physician supply for otolaryngology. A focus group of otolaryngologists provided information to model future scenarios. RESULTS: The current and predicted workforce supply and demographics are at a satisfactory level and are decreasing as a proportion of the increasing population. Empiric data analysis supports the diverse nature of an otolaryngologists practice and the unique role for otolaryngologists that is not shared by many other providers. Together with the focus group results, the study points to areas for which more background and training are warranted. CONCLUSIONS: This study represents a first step in a process to form coherent workforce recommendations for the field of otolaryngology.

Frontal sinus obliteration using liposuction.

Frontal sinus obliteration is performed for a variety of reasons, including chronic sinus disease, traumatic injuries, mucoceles, and osteomas of the sinus. Once the decision is made to obliterate the sinus, it is paramount that all mucosal remnants be removed and that the material used to fill the irregular expanses of the frontal sinus help prevent recurrence of the disease process. The materials most commonly used for this purpose are fat, muscle, and pericranium. Fat obtained from the abdomen, gluteal area, or lateral thigh is probably the most frequently used substance. The procurement of fat in the traditional way adds significant time to the operation and is associated with significant morbidity at the donor site. Fat obtained in this manner is often bulky and does not truly conform to the sinus contour. In an attempt to minimize operating time and donor-site morbidity—as well as obtain a more malleable graft—we used liposuction to obtain our fat grafts for sinus obliteration. Using this method, we were able to obtain an adequate amount of tissue from either the abdomen or lateral thigh in all patients. We have used this technique in eleven patients, with follow-ups ranging from 3 to 18 months. We have had no donor-site morbidity and (to date) there has been no recurrence of sinus disease in these patients. While the follow-up period is not adequate for final evaluation in these patients, we believe this is a valuable adjunct to frontal sinus surgery.

Regent A New Otolaryngology Clinical Data Registry

The accelerating transition to a “quality based” health care delivery model through legislative, regulatory, and marketplace intervention will require objective determination and reporting of what constitutes “best care” and enhances value within the system. The ability to produce reliable and reproducible results will be critical to those who want to maximally participate in this evolving paradigm. Databases such as CHEER (Creating Healthcare Excellence through Education and Research) and the one being developed by the American Academy of Otolaryngology—Head and Neck Surgery Foundation in its clinical data registry Regent, which Bellmunt et al discuss in this issue of the journal, will be the key to compiling the evidence necessary for our members to meaningfully share in the progress toward better patient care while complying with the reporting requirements built into the post-MACRA environment (ie, Medicare Access and Children’s Health Insurance Program Reauthorization Act). Registries created by other specialty societies have accumulated massive numbers of patient encounters in relatively short time frames that have allowed risk-adjusted clinical observations across the gamut of practice types and locations, creating the ability for each society to define clinical parameters most relevant to the patients treated by its members. The pooling of data from private practice and academic settings across all geographic areas of the country creates a powerful resource to move clinical medicine forward. Initially, the most tangible benefit will be realized in public quality reporting that is required by the Physician Quality Reporting System and its Merit-Based Payment System successor. Regent was granted Qualified Clinical Data Registry status for 2016, which will allow for a seamless reporting process by members, as well as the ability to create up to 30 otolaryngologyspecific measures for reporting and quality improvement. As the registry becomes more established, performance e-measures can be created in a more timely fashion with significant cost savings when compared with de novo construction of performance measures. This will allow the production of measures across the breadth of the specialty and the transformation to outcomes measures that will be necessary in future years. This type of data will allow us to identify “best care” options for even less common disease processes. Research opportunities will be rich and make the study of rare conditions possible. We will be able to follow the natural history of multiple diseases and compare available treatment options in real time. There have been upward of 900 publications emanating from the cardiology registries alone. We anticipate that multiple opportunities for clinical research paralleling the experience of other specialties will present themselves from the Regent data. On the road toward outcome measures and data, we will also have the opportunity to document and measure performance improvement, which is a key element in both the Merit-Based Payment System and the Maintenance of Certification process. Performance gaps can be more easily identified and the improvements quantified. The American Board of Otolaryngology is an active participant with the American Academy of Otolaryngology— Head and Neck Surgery Foundation in Regent, which will facilitate the coordination of Maintenance of Certification activities from the outset. We anticipate that the registry will also be an important contributor to Maintenance of Licensure requirements as they expand. Finally, a clinical data registry is the perfect vehicle for both initial and long-term surveillance of medical devices and pharmaceuticals. There is significant interest from the Food and Drug Administration in partnering with specialty-based registries in this process. The utility of Regent will depend on the number of participants. Over time we would hope to enroll the majority of otolaryngologists in the United States. The larger the pool of data that we can collect, the greater influence that we will have in providing the best care for our patients.

Board of Governors’ Hot Topic 2014: Will Fee for Service Survive?

Program Description: On the hinge of health care reform, the Board of Governors’ (BOG’s) 2014 hot topic is: will fee for service survive? Expert panelists, consisting of American Academy of Otolaryngology—Head and Neck Surgery presidents, BOG chairs, and physician payment and policy workgroup members, will discuss if fee for service will be superseded by payments based on work relative value units, quality measures, hospital employment, and bundled payments. Presentations will be made on current and past payment structures, bundled payments, quality metrics, and the sustainability of private practice. Time for interaction between the audience and panelists will be ensured through a final round table discussion. Educational Objectives: (1) Describe the history of fee for service and how it has changed in the past 10 years. (2) Relate the impact of health care reform on current and future payment systems. (3) Recognize the challenges private practice will have with new reimbursement models.

Hot Topics in Otolaryngology 2013: Accountable Care Organizations

Program Description: The practice of medicine is rapidly transforming in response to healthcare reform and cost reduction efforts. ACOs, first introduced into the Patient Protection and Affordable Care Act in 2009, are a payment and care delivery model that tie reimbursements to performance and cost reduction for a defined patient population. The physician must understand the laws and economics that affect the delivery of healthcare. Participants will gain an understanding of 1) Healthcare laws 2) ACOs, with a focus on outcomes, safety, and satisfaction while decreasing costs, negotiation tactics, and methods of awarding any shared savings. 3) Socioeconomic factors and concerns regarding emerging payment paradigms. Educational Objectives: 1) Evaluate the current and future impact of Federal Healthcare Regulations upon otolaryngologic practice. 2) Comprehend physician and hospital organized ACOs, their objectives and considerations that will affect your role within that structure. 3) Recognize socioeconomic concerns related to transitioning from a fee for service model into ACOs and other future payment paradigms and what the Board of Governors is doing on behalf of our members.

Alternative Payment Models and Academy Advocacy

Program Description: The physician payment landscape is changing as quality measures become more intertwined with payment. This miniseminar outlines the efforts of the Physician Payment Policy Work Group (3P) to prepare members for the implementation of the Affordable Care Act by giving them the tools to participate in diverse payment systems. Topics include public and private payment models including accountable care organizations (ACOs), bundling, and the importance of measures in the future of quality and payment initiatives. Presenters will discuss strategies including how resources such as Clinical Indicators and Policy Statements are used to advocate for appropriate policies by health insurance companies for coverage of services. Educational Objectives: 1) Comprehend future healthcare reform initiatives, new payment models, and Academy efforts to prepare members for changes to how they will receive payment for services. 2) Recognize the measure sets we have formally developed in otolaryngology (sinusitis, otitis externa/otitis media) and how many providers can and will apply these measures to practice. 3) Be aware of Academy strategies for interaction with public and private payers and effective membership involvement.

Miniseminar: Physician Payment Policy: Unraveling the Mystery

Abstract Physician reimbursement has changed drastically since the advent of the RBRVS methodology by Medicare in the late 1980s. Physician payment policy has evolved into a complex, multi-faceted exercise that now involves private payers as well and affects all aspects of medical practice. It is imperative that physicians understand how the payment system works. This will allow the medical community to objectively evaluate utilization of limited resources to maximize the evolution of effective patient care. The payment system also plays a great role in the scope of practice decisions being made in all areas of medicine and the legislative and regulatory posturing reshaping the entire health delivery system. The Panel will discuss in an interactive fashion with the audience: (1) the evolution of the RBRVS payment system to today’s version; (2) how the CPT, RUC, and PEAC function; (3) how physicians can use the system to evaluate their practice and new technologies; (4) how academy members can influence policy to benefit otolaryngology and their patients.