Raj Sindwani

Contrasting the Microbiomes From Healthy Volunteers and Patients With Chronic Rhinosinusitis

IMPORTANCE Chronic rhinosinusitis (CRS) is the persistent inflammation of the sinus and nasal passages lasting over 3 months. The etiology of CRS is not well understood. OBJECTIVE To obtain insights into the disease process, we contrasted the microbiome and immune response from patients with CRS and healthy controls. DESIGN, SETTING, AND PARTICIPANTS A case vs control design was used. Samples were collected in the operating room in an institutional hospital or clinic. Thirty patients with CRS and 12 healthy controls undergoing surgery were recruited. MAIN OUTCOMES AND MEASURES The microbiome was analyzed by deep sequencing of the bacterial 16S and fungal 18S ribosomal RNA genes. Immune response was measured by quantification of 30 different cytokines by multiplexed enzyme-linked immunosorbent assay, and immune cells in the lavage were identified by flow cytometry. The immune response of peripheral blood leukocytes to the lavage microbiota was assessed by interleukin (IL)-5 enzyme-linked immunospot assay. RESULTS While quantitative increase in most bacterial and fungal species was observed in patients with CRS relative to controls, the microbiomes of patients with CRS were qualitatively similar to the controls. Because these results indicated that bacteria and fungi are not triggering CRS, we undertook a more detailed characterization of the immune response. Patients with CRS had increased levels of the following cytokines: IL-4, IL-5, IL-8, and IL-13, along with increased levels of eosinophils and basophils in the lavage. Importantly, peripheral blood leukocytes isolated from patients with CRS responded to control lavage samples (ie, to commensals) to produce IL-5. In contrast, the same lavage sample evoked no IL-5 production in leukocytes from healthy controls. CONCLUSIONS AND RELEVANCE These findings support the theory that in some cases CRS results from an immune hyperresponsiveness to commensal organisms.

International Consensus Statement on Allergy and Rhinology: Rhinosinusitis

Isam Alobid, MD, PhD1, Nithin D. Adappa, MD2, Henry P. Barham, MD3, Thiago Bezerra, MD4, Nadieska Caballero, MD5, Eugene G. Chang, MD6, Gaurav Chawdhary, MD7, Philip Chen, MD8, John P. Dahl, MD, PhD9, Anthony Del Signore, MD10, Carrie Flanagan, MD11, Daniel N. Frank, PhD12, Kai Fruth, MD, PhD13, Anne Getz, MD14, Samuel Greig, MD15, Elisa A. Illing, MD16, David W. Jang, MD17, Yong Gi Jung, MD18, Sammy Khalili, MD, MSc19, Cristobal Langdon, MD20, Kent Lam, MD21, Stella Lee, MD22, Seth Lieberman, MD23, Patricia Loftus, MD24, Luis Macias‐Valle, MD25, R. Peter Manes, MD26, Jill Mazza, MD27, Leandra Mfuna, MD28, David Morrissey, MD29, Sue Jean Mun, MD30, Jonathan B. Overdevest, MD, PhD31, Jayant M. Pinto, MD32, Jain Ravi, MD33, Douglas Reh, MD34, Peta L. Sacks, MD35, Michael H. Saste, MD36, John Schneider, MD, MA37, Ahmad R. Sedaghat, MD, PhD38, Zachary M. Soler, MD39, Neville Teo, MD40, Kota Wada, MD41, Kevin Welch, MD42, Troy D. Woodard, MD43, Alan Workman44, Yi Chen Zhao, MD45, David Zopf, MD46

Impact of Image Guidance on Complications During Osteoplastic Frontal Sinus Surgery

OBJECTIVES: To evaluate the impact of image-guidance technology on intraoperative complications during frontal sinus obliteration surgery. STUDY DESIGN AND SETTING: Retrospective case control. Twenty-four patients underwent frontal sinus obliteration with image-guidance technology (n = 15) or conventional instrumentation (n = 9) between 1992 and 2003. The image-guidance system was used to delineate the frontal sinus perimeter and direct cuts through the frontal bone. RESULTS: Intraoperative complications occurred in none of the patients in the image-guidance group and in 3 patients in the control group (P = 0.042). Adverse events included dural tear with CSF leak in 2 patients and exposure of orbital fat in 1 patient. The incidence of postoperative complications was similar between groups (P = 0.326). No patients required revision surgery. Mean follow-up was 5.2 years. CONCLUSIONS: The use of surgical navigation during frontal sinus obliteration appears to improve intraoperative safety. SIGNIFICANCE: This is the first report to document a reduction in the rate of intraoperative complications when image guidance is utilized for frontal sinus surgery.

Early versus Delayed Endoscopic Sinus Surgery in Patients with Chronic Rhinosinusitis: Impact on Health Care Utilization

Objective To evaluate the impact of early versus delayed endoscopic sinus surgery (ESS) in terms of postoperative health care utilization, using a patient cohort with chronic rhinosinusitis (CRS). Study Design Retrospective administrative database analysis. Setting US-based primary and secondary sites of care. Subjects and Methods CRS patients with ESS in 2010—with no other ESS before 2010 and with complete medical history from 2004 to 2012—were identified within the MarketScan database. Patients were characterized by time interval of first sinusitis or nasal polyposis diagnosis to ESS and grouped as following: group 1, < 1 year (n = 818); group 2, 1 to <2 years (n = 247); group 3, 2 to <3 years (n = 274); group 4, 3 to <4 years (n = 364); group 5, 4 to <5 years (n = 595); and group 6, ≥5 years (n = 535). Outpatient visits/procedures and prescriptions associated with sinusitis and/or nasal polyps were analyzed for 1 year preoperatively and 2 years postoperatively. Subanalyses were conducted on separate cohorts with or without asthma or polyps, within each group. Results Patients in group 1 had significantly fewer visits and prescriptions than patients in group 6 (postoperative visits: group 1, 4.45 [95% CI, 4.06-4.84]; group 6, 6.70 [95% CI, 6.10-7.30; prescriptions: group 1, 4.54 [95% CI, 4.12-4.96]; group 6, 7.61 [95% CI, 6.92-8.31]). Gradual increases in utilization were observed from groups 1 to 6. Subanalysis of patients with and without asthma or polyps showed similar findings. Conclusion Early intervention after diagnoses of CRS, with or without asthma or polyps, is associated with lower health care utilization than intervention after many years of medical management.

Balloon catheter technology in rhinology: Reviewing the Evidence

Balloon catheter technology (BCT) for management of paranasal sinus inflammatory disease was introduced to otolaryngology in 2005. Since its introduction, BCT has been a subject of considerable controversy with proponents for and against adoption of the technology. Balloon procedures have been promoted as a less invasive alternative to endoscopic sinus surgery that results in reduced pain and quicker recovery. The technology and its promotion have generated significant press coverage and interest by the lay public looking for new solutions for sinonasal problems. Over time, alternate balloon devices have been advocated for operating room and office‐based sinus ostia dilatation. This contemporary review will evaluate the existing evidence on the available balloon devices. The frank strengths and weaknesses of the peer‐reviewed literature will be highlighted. The potential complications unique to balloon catheters and radiation exposure from fluoroscopy will also be discussed. Laryngoscope, 2011

Microporous polysaccharide hemospheres do not increase synechiae after sinus surgery: randomized controlled study.

Background Many surgeons use absorbable packing materials after endoscopic sinus surgery (ESS). Despite their popularity, some of these agents have been shown to contribute to synechiae formation. Microporous polysaccharide hemospheres (MPH) is a plant-based hemostatic powder that does not interfere with regenerating sinus mucosa in the animal model. The goal of this study was to examine the impact of MPH on healing and synechiae formation after ESS in human subjects. Methods A prospective, randomized, controlled, double-blind study was performed. Forty consenting adult patients with chronic sinusitis requiring symmetric ESS were randomized to receive MPH unilaterally at the conclusion of surgery. The opposite side was untreated. Standard postoperative care was performed bilaterally. Outcomes measured included blinded observer ratings for synechiae formation, edema, and infection. Each side was examined endoscopically and scored at postoperative days 7, 14, and 30. Results Twenty men and 20 women with an average age of 48.2 years were included. There were no complications and all patients were discharged home the same day. There was no significant difference in synechiae formation at any point postoperatively. The rate of synechiae formation was determined to be 10% (4/40) on the MPH-treated side versus 7.5% (3/40) on the untreated side (p = 0.7639). In addition, there were no significant differences observed in edema (p = 0.7480) or infection (p = 0.5533). Conclusion The use of MPH after sinus surgery does not increase synechiae formation and does not appear to deleteriously affect the healing of postoperative sinus cavities.

Development of a Quality Care Plan to Reduce Otolaryngologic Readmissions Early Lessons from the Cleveland Clinic

Objectives Hospital readmissions are an important focus of national quality and cost containment efforts. With increased emphasis on the impact of unplanned readmissions, it is critical to evaluate factors contributing to readmission rates and optimize strategies aimed at reducing these rates. The objectives of this study were to discuss quality interventions implemented at our institution and to evaluate their impact on reducing readmissions. Study Design Case series with chart review. Setting Academic tertiary care medical center. Methods Medical records of patients who were admitted to an otolaryngology inpatient service and readmitted within 30 days of discharge between January 2010 and December 2012 were reviewed. A quality care plan (QCP) was developed, and various interventions were implemented during this time to affect these rates. Results There were 769, 816, and 798 admissions during the years 2010, 2011, and 2012, respectively. The number of readmissions during this time were 50 (6.5%), 51 (6.3%), and 28 (3.5%), respectively. There were no statistically significant differences in case mix index, demographics, and subsequent length of stay for those patients requiring readmission. The reduction in number of readmissions in 2012, after the institution of our QCP, was statistically significant (P < .05). Conclusion Readmission within 30 days in a large otolaryngology practice can be multifactorial. To reduce rates of readmission, it is essential to understand the diagnoses, postoperative complications, and comorbidities contributing to readmission. Implementation of a QCP composed of comprehensive discharge planning and close postdischarge follow-up can lead to a reduction in readmissions.

Transoral and transnasal odontoidectomy complications: A systematic review and meta-analysis

OBJECT The craniovertebral junction (CVJ) is a complex region of the spine with unique anatomical and functional relationships. To alleviate symptoms associated with pathological processes involving the odontoid process, decompression is often required, including odontoidectomy. Accurate knowledge of the complication rates following the transoral and transnasal techniques is essential for both patients and surgeons. METHODS We conducted MEDLINE, Scopus and Web of Science database searches for studies reporting complications associated with the transoral and transnasal techniques for odontoidectomy. Case series presenting data for less than three patients were excluded. Rates of complication and clinical outcomes were calculated and subsequently analyzed using a fixed-effects model to assess statistical significance. RESULTS Of 1288 articles retrieved from MEDLINE, Scopus, and Web of Science, twenty-six met inclusion criteria. Transoral and transnasal procedures resulted in the following respective complication rates: arterial injury 1.9% and 0.0%, intraoperative CSF leak 0.3% and 30.0%, postoperative CSF leak 0.8% and 5.2%, 30-day mortality 2.9% and 4.4%, medical complications 13.9% and 28.6%, meningitis 1.0% and 4.0%, pharyngeal wound dehiscence 1.7% (transnasal not reported), pneumonia 10.3% (transnasal not reported), prolonged or re-intubation 5.6% and 6.0%, reoperation 2.5% and 5.1%, sepsis 1.9% and 7.7%, tracheostomy 10.8% and 3.4%, velopharyngeal insufficiency 3.3% and 6.4% and wound infection 3.3% and 1.9%. None of these differences were statistically significant, except for postoperative tracheostomy, which was significantly higher after transoral odontoidectomy 8.4% (95% CI 4.9% -11.9%) compared to transnasal odontoidectomy 0.8% (95% CI -1.0% -2.9%). Neurologic outcome was improved in 90.0% and worse in 0.9% of patients after transoral compared to 94.0% and 0.0% after transnasal odontoidectomy (p=0.30). CONCLUSIONS This work presents a systematic review of complications reported for transoral or transnasal odontoidectomy across a heterogeneous group of surgeons and patients. Due to inconsistent reporting, statistical significance was only achieved for postoperative tracheostomy, which was significantly higher in the transoral group. This investigation sets the framework for further discussions regarding odontoidectomy approach options and their associated complications during the informed consent process.

Inferior turbinate hypertrophy: review and graduated approach to surgical management.

Background Surgical techniques for managing inferior turbinate hypertrophy (ITH) vary widely and have evolved substantially in the past four decades as new technologies have emerged. Methods Literature review. Results Inferior turbinate (IT) procedures can be categorized as: simple turbinate outfracture; turbinoplasty techniques such as extramucosal destruction, and submucosal tissue removal; and extramural turbinate resection (partial or complete). Each of these approaches has advantages and drawbacks. Considerations for technique selection include clinical setting (in-office versus operating room), cost of the devices used, efficacy of the procedure to relieve nasal obstruction, and minimizing postoperative complications such as nuisance bleeding, adhesion formation, and crusting. Conclusion There are a variety of contemporary surgical techniques used for IT reduction. This article highlights the available literature and gaps in current knowledge. A graduated approach to the management of ITH will be presented.

Myospherulosis Following Sinus Surgery: Pathological Curiosity or Important Clinical Entity?†

Objectives/Hypothesis Myospherulosis is a foreign body reaction to lipid material used on nasal packing at the conclusion of sinus surgery. This reaction has been associated with postoperative adhesion formation. The purpose of the study was to determine whether the occurrence of myospherulosis has an adverse effect on clinical outcome following sinus surgery.