Sean Carrie

Sinonasal inverted papilloma: narrative review

BACKGROUND Sinonasal inverted papilloma is a benign condition with the potential for recurrence and malignant change. Over the past few decades, numerous studies and reviews have addressed different aspects of this condition. OBJECTIVE To amalgamate the current literature on inverted papilloma, in order to review the evidence and consider the gaps in current knowledge. METHODS Retrospective, narrative review. RESULTS The reported incidence of inverted papilloma varies between centres and is affected by selection bias. The exact aetiology of inverted papilloma is not fully understood. Currently, there is no reliable histological or biological marker to predict the probability of recurrence or malignant transformation. There is no universally accepted staging system available for sinonasal inverted papilloma. Complete surgical removal of the tumour is the mainstay of treatment, but the method of choice depends on the extent of the disease, the skill of the surgeon and the technology available. CONCLUSION In order to compare different studies and to enable meta-analysis of the literature, there should be a universally accepted staging and classification system for sinonasal inverted papilloma. Further research on the aetiology of sinonasal inverted papilloma, and on biological markers for its recurrence and malignant transformation, is required. To enable meaningful future research, we would encourage multicentre participation with a consensus on management.

Endoscopic versus open surgical interventions for inverted nasal papilloma: a systematic review

• Inverted nasal papilloma is a unique neoplasm characterised by a tendency to recur following excision, an association with malignancy and an ability to destroy bone.

The burden of revision sinonasal surgery in the UK-data from the Chronic Rhinosinusitis Epidemiology Study (CRES): a cross-sectional study.

Objectives The aim of this study was to investigate the surgical revision rate in patients with chronic rhinosinusitis (CRS) in the UK CRS Epidemiology Study (CRES). Previous evidence from National Sinonasal Audit showed that 1459 patients with CRS demonstrated a surgical revision rate 19.1% at 5 years, with highest rates seen in those with polyps (20.6%). Setting Thirty secondary care centres around the UK. Participants A total of 221 controls and 1249 patients with CRS were recruited to the study including those with polyps (CRSwNPs), without polyps (CRSsNPs) and with allergic fungal rhinosinusitis (AFRS). Interventions Self-administered questionnaire. Primary outcome measure The need for previous sinonasal surgery. Results A total of 651 patients with CRSwNPs, 553 with CRSsNPs and 45 with AFRS were included. A total of 396 (57%) patients with CRSwNPs/AFRS reported having undergone previous endoscopic nasal polypectomy (ENP), of which 182 of the 396 (46%) reported having received more than one operation. The mean number of previous surgeries per patient in the revision group was 3.3 (range 2–30) and a mean duration of time of 10 years since the last procedure. The average length of time since their first operation up to inclusion in the study was 15.5 years (range 0–74). Only 27.9% of all patients reporting a prior ENP had received concurrent endoscopic sinus surgery (ESS; n=102). For comparison, surgical rates in patients with CRSsNPs were significantly lower; 13% of cases specifically reported ESS, and of those only 30% reported multiple procedures (χ2 p<0.001). Conclusions This study demonstrated that there is a high burden of both primary and revision surgery in patients with CRS, worst in those with AFRS and least in those with CRSsNPs. The burden of revision surgery appears unchanged in the decade since the Sinonasal Audit.

Clinical outcome of endonasal KTP laser assisted dacryocystorhinostomy

BackgroundTo evaluate the clinical outcome of primary endonasal laser assisted dacryocystorhinostomy (ENL-DCR) using the potassium-titanyl-phosphate laser.MethodsWe retrospectively reviewed all primary ENL-DCRs performed within a period of twelve months by the same combined Ophthalmology and Otorhinolaringology team in Freeman Hospital, Newcastle upon Tyne, UK. The main outcome measure for success was resolution or significant improvement of epiphora. Details of surgery, intraoperative and postoperative complications, as well as pathology associated with failure were also studied. Patients were followed up for at least 12 months.ResultsA total of 41 consecutive ENL-DCRs on 29 patients (22 females, 7 males, mean age 75 years) were analysed. All patients had bicanalicular silicone intubation for at least 4 months. The success rate at 12 months postoperatively was 78.1%. Pathology associated with failure included: intranasal pathology (12.2%), mucocele (7.3%), and systemic sarcoidosis (2.4%). No significant intra-operative complications were recorded.ConclusionThe ENL-DCR with potassium-titanyl-phosphate laser can be considered as a safe and efficient primary procedure for the treatment of nasolacrimal duct obstruction.

Quality of life assessment after non-laser endonasal dacryocystorhinostomy

Objective:  There has been a lack of patient‐centred evidence in the Otolaryngology literature, that non‐laser endonasal dacryocystorhinostomy improves the quality of life of patients. Many studies demonstrate successful outcomes based on non‐validated subjective patient reporting. The aim of this survey was to evaluate the impact of non‐laser endonasal dacryocystorhinostomy on the quality of life of patients using a validated questionnaire, the Glasgow Benefit Inventory (GBI).

Tonsillectomy A Cost-Effective Option for Childhood Sore Throat? Further Analysis of a Randomized Controlled Trial

Objective. To compare the estimated cost-effectiveness of childhood (adeno)tonsillectomy vs medical therapy for recurrent sore throats from the intention-to-treat (ITT) analysis of a randomized controlled trial (RCT) with that modeled on the recorded timing of surgical interventions as observed in all participants irrespective of their original group allocation. Study Design. A pragmatic RCT (trial) with a parallel nonrandomized patient preference group (cohort) of (adeno)tonsillectomy vs medical therapy. Setting. Five secondary care UK otolaryngology departments. Subjects and Methods. Eligible children, aged 4 to 15 years, were enrolled to the trial (268) or cohort (461) groups. Outcomes included sore throat diaries, quality of life, and general practice consultations. The RCT protocol ITT analysis was compared with an as-treated analysis incorporating the cohort group, modeled to reflect the timing of tonsillectomy and the differential switch rates among the original groups. Results. >In the RCT ITT analysis, tonsillectomy saved 3.5 sore throats, whereas the as-treated model suggested an average reduction of more than 8 sore throats in 2 years for surgery within 10 weeks of consultation, falling to only 3.5 twelve months later due to the spontaneous improvement in the medical therapy group. Conclusion. In eligible UK school-age children, tonsillectomy can save up to 8 sore throats at a reasonable cost, if performed promptly. Further prospective data collection, accounting for baseline and per-trial preferences and choice, is urgently needed.OBJECTIVE To compare the estimated cost-effectiveness of childhood (adeno)tonsillectomy vs medical therapy for recurrent sore throats from the intention-to-treat (ITT) analysis of a randomized controlled trial (RCT) with that modeled on the recorded timing of surgical interventions as observed in all participants irrespective of their original group allocation. STUDY DESIGN A pragmatic RCT (trial) with a parallel nonrandomized patient preference group (cohort) of (adeno)tonsillectomy vs medical therapy. SETTING Five secondary care UK otolaryngology departments. SUBJECTS AND METHODS Eligible children, aged 4 to 15 years, were enrolled to the trial (268) or cohort (461) groups. Outcomes included sore throat diaries, quality of life, and general practice consultations. The RCT protocol ITT analysis was compared with an as-treated analysis incorporating the cohort group, modeled to reflect the timing of tonsillectomy and the differential switch rates among the original groups. RESULTS In the RCT ITT analysis, tonsillectomy saved 3.5 sore throats, whereas the as-treated model suggested an average reduction of more than 8 sore throats in 2 years for surgery within 10 weeks of consultation, falling to only 3.5 twelve months later due to the spontaneous improvement in the medical therapy group. CONCLUSION In eligible UK school-age children, tonsillectomy can save up to 8 sore throats at a reasonable cost, if performed promptly. Further prospective data collection, accounting for baseline and per-trial preferences and choice, is urgently needed.

MUC5B secretion is up-regulated in sinusitis compared with controls

Background The mucus that lines the airway epithelium provides a barrier against pathogenic and noxious agents and participates in the innate mucosal response to inflammation and infection. Mucins are the major components of mucus and the macromolecules that impart rheologic properties to airway mucus. Airway mucus is overproduced in chronic rhinosinusitis (CRS). Biochemical and biophysical characterization of mucus in CRS and in normal airways will elucidate important aspects of CRS pathophysiology and allow the design of targeted medical treatments. The aim of this study was to estimate secretion of sinus mucus mucins in healthy individuals and CRS and correlate them with mucus biophysical properties. Methods Twenty-seven sinus mucus samples from 21 patients were collected (14 subjects with CRS undergoing sinus surgery as part of their treatment and 7 control subjects undergoing hypophysectomy without sinonasal disease). Biophysical properties of the mucus were measured by rheometry. ELISA was done to estimate MUC5AC and MUC5B mucin content in comparison with standards, i.e., porcine gastric mucin (MUC5AC) and human salivary mucin (MUC5B). Results MUC5B secretion ± SEM was 0.49 ± 0.16 μg/mL (n = 14) and 0.17 ± 0.05 μg/mL (n = 7) and MUC5AC secretion ± SEM was 1.26 ± 0.26 μg/mL (n = 14) and 1.46 ± 0.61 μg/mL (n = 7) in chronic sinusitis and control subjects, respectively. There was linear correlation between viscosity and mucin content in the control group but not in the CRS group. Conclusion MUC5B secretion is significantly up-regulated in CRS compared with control subjects (p = 0.04). Correlation between viscosity and mucin content was lost in CRS. This is likely to have important implications for future therapies in CRS.

Childhood tonsillectomy: who is referred and what treatment choices are made? Baseline findings from the North of England and Scotland Study of Tonsillectomy and Adenotonsillectomy in Children (NESSTAC)

Background Tonsillectomies are frequently performed, yet variations exist in tonsillectomy rates. Clinicians use guidelines, but complex psychosocial influences on childhood tonsillectomy include anecdotal evidence of parental enthusiasm. Studies indicate that undergoing preferred treatment improves outcome. Despite the enthusiasm with which tonsillectomy is offered and sought, there is little evidence of efficacy. This resulted in a randomised controlled trial to evaluate the cost-effectiveness of (adeno)tonsillectomy in children with recurrent sore throats. Objective To compare characteristics of children entering the randomised trial with those recruited to a parallel, non-randomised study, to establish trends in referral and patient preferences for treatment. Design Baseline data from a randomised controlled trial with parallel non-randomised preference study, comparing surgical intervention with medical treatment in children aged 4–15 years with recurrent sore throat referred to five secondary care otolaryngology departments located in the north of England or west central Scotland. Results Centres assessed 1546 children; 21% were not eligible for tonsillectomy. Among older children (8–15 years), girls were significantly more likely to be referred to secondary care. Of 1015 eligible children, 268 (28.2%) agreed to be randomised, while 461 (45.4%) agreed to the parallel, non-randomised preference study, with a strong preference for tonsillectomy. Participants reporting that progress at school had been impeded or with more experience of persistent sore throat were more likely to seek tonsillectomy. Referred boys were more likely than girls to opt for medical treatment. Socio-economic data showed no effect. Conclusion Preference for tonsillectomy reflects educational impact and recent experience, rather than age or socio-economic status.

Diagnosis and management of olfactory disorders: survey of UK-based consultants and literature review.

BACKGROUND The diagnosis and management of olfactory disorders is an often neglected topic in otolaryngology. This article evaluates current clinical practice within the United Kingdom, and provides a literature-based review of the diagnosis, management and prognosis of olfactory pathology. DESIGN A questionnaire was sent to consultant and associate specialist members of the British Association of Otolaryngologists and Head and Neck Surgeons. The responses were documented to gain an impression of how olfactory disorders are managed in the United Kingdom. The literature relating to olfactory dysfunction was then evaluated and the findings summarised. CONCLUSIONS Management of olfactory pathology varies across the United Kingdom. The literature suggests that chemosensory testing is optimal and that both forced-choice and threshold testing should be applied if objective evaluation is required. Imaging can be of value but the appropriate technique should be used. Olfactory function can recover following head injury, viral infection and chronic sinonasal disease, although varying degrees of dysfunction are likely to persist. There is a role for the use of corticosteroids, particularly when administered systemically. More research is needed to establish the appropriate dose and length of treatment.

The significance of MRI findings for non‐rhinological disease*

Objectives:  Mucosal changes in the paranasal sinuses are detected in 30–50% of scans for non‐rhinological disease. This study assesses the relationship between symptoms of rhinosinusitis and radiological evidence of sinus pathology in patients undergoing magnetic resonance imaging (MRI) scans for unrelated pathology.