Shahram Anari

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.

Neonatal disseminated methicillin-resistant Staphylococcus aureus presenting as orbital cellulitis

Orbital cellulitis and abscess are known complications of ethmoiditis in children, but they are very rare in the newborn. The authors report a case of orbital abscess caused by methicillin-resistant Staphylococcus aureus (MRSA) in a four-week-old neonate born four weeks prematurely.

A case-control study of medical, psychological and socio-economic factors influencing the severity of chronic rhinosinusitis.

BACKGROUND Chronic rhinosinusitis (CRS) is a common and debilitating disorder. Little is known about the epidemiology of this disease. The aims of the study were to identify differences in socio-economic variables and quality of life between patients with chronic rhinosinusitis and healthy controls, to identify any significant associations between CRS and other medical co-morbidities, psychiatric disease or environmental exposure and to explore the experience of CRS from the perspective of CRS sufferers. METHODS Participants were recruited from ENT clinics from 30 centres across the UK. They completed a study-specific questionnaire considering environmental, medical and socio-economic factors, and SF-36 and SNOT-22 scores. All participants with CRS were diagnosed by a clinician and categorised as having CRS (with polyposis, without polyposis or allergic fungal rhinosinusitis (AFRS)). Controls included family and friends of those attending ENT outpatient clinics and hospital staff who had no diagnosis of nose or sinus problems and had not been admitted to hospital in the previous 12 months. RESULTS A total of 1470 study participants (1249 patients and 221 controls) were included in the final analysis. Highly significant differences were seen in generic and disease-specific quality of life scores between CRS sufferers and controls; mean SNOT-22 score 45.0 for CRS compared with 12.1 amongst controls. There were no clear differences in socioeconomic variables including social class, index of multiple deprivation and educational attainment between cases and controls. Common comorbidities with a clear association included respiratory and psychiatric disorders, with a higher frequency of reported upper respiratory tract infections. CONCLUSIONS CRS is associated with significant impairment in quality of life and with certain medical co-morbidities. In contrast to other common ENT disorders, no socioeconomic differences were found between patients and controls in this study.

SNOT-22 in a control population.

To assess SNOT‐22 and its subscales in a non‐rhinosinusitis UK‐wide population.

Silencing the snorers : no gain without pain?

OBJECTIVE To compare the estimated effects of conservative surgery to those of a mandibular advancement splint (MAS) in the treatment of habitual snoring. METHOD Prospective, observational, non-randomized cohort study. RESULTS Adequate follow-up data were available for 88 participants (23 following coblation, 65 after provision of an MAS). The mean reduction in snoring symptoms inventory (SSI) score for the 23 subjects undergoing coblation was 9.83 (+/-standard deviation 11.43). Reported pain duration was greatest with uvula amputation, but uvula coblation did not always adequately reduce its bulk. Of the 65 MAS patients, 39 (60 per cent) used the device regularly, with a mean fall in SSI of 12 (+/-16.4, p=0.001). Approximately one in four patients in both groups achieved a significant fall in SSI (>15 points), and the measured effect sizes were close to 0.75 for both treatments. CONCLUSIONS Mandibular advancement splints and coblation have similar efficacies. However, their efficacy does not match that of radical surgery.

Chronic rhinosinusitis and mood disturbance

BACKGROUND This study is part of the Chronic Rhinosinusitis Epidemiology Study (CRES). The overarching aim is to determine factors that influence the onset and severity of chronic rhinosinusitis (CRS). The aim of this analysis is to determine whether those with CRS are more likely to report psychiatric morbidity and in particular mood disturbance compared with healthy controls. METHODS CRES consists of a study-specific questionnaire regarding demographic and socioeconomic factors and past medical history as well as a nasal symptom score (SNOT-22) and SF-36 (QoL - quality of life tool). Both of these tools contain mental health or emotional well-being domains. Participants were specifically asked whether they had ever consulted with their General Practitioner for anxiety or depression. Questionnaires were distributed to patients with CRS attending ENT outpatient clinics at 30 centres across the United Kingdom from 2007-2013. Controls were also recruited at these sites. Patients were divided into subgroups of CRS according to the absence/presence of polyps (CRSsNPs/CRSwNPs) or allergic fungal rhinosinusitis (AFRS). RESULTS Consultations with a family physician for depression or anxiety were higher amongst those with CRS than controls, but this was only significant for those with CRSsNPs. Odds ratio (OR) for CRSsNPs vs controls: 1.89; OR for CRSwNPs: 1.40. Patients with CRS showed significantly higher mental health morbidity than controls across the mental health and emotional wellbeing domains of the SF-36 and SNOT-22. Mean difference in the mental health domain of SF-36 was 8.3 for CRSsNPs and 5.3 for CRSwNPs. For the emotional domain of SNOT-22, differences were 7.7 and 6.3 respectively. CONCLUSIONS Depression and anxiety are significantly more common in patients with CRS compared to healthy controls, especially in those with CRSsNPs. This added mental health morbidity needs consideration when managing these patients in primary and secondary care settings.

A cross sectional analysis of a case-control study about quality of life in CRS in the UK; a comparison between CRS subtypes

BACKGROUND The Sinonasal Outcome Test (SNOT-22) has been used as a patient reported outcome measure to grade symptom severity before and after treatment for chronic rhinosinusitis (CRS). METHODOLOGY This analysis uses data from the CRS Epidemiology Study (CRES). The overarching aim of CRES was to determine factors that influence the onset and severity of CRS. A study-specific questionnaire including SNOT-22 was distributed to patients with CRS attending ENT clinics across 30 centres in the United Kingdom. The aim of this analysis was to compare SNOT-22 scores between those with different types of CRS to determine any differences present in the total score or the subdomains and to assess whether any differences varied according to gender. RESULTS There were a total of 1249 CRS participants in the following subgroups: CRS without nasal polyps (CRSsNPs) (n=553), CRS with nasal polyps (CRSwNPs) (n=651), allergic fungal rhinosinusitis (AFRS) (n=45). Since there were differing gender ratios in each subgroup, males and females were analysed separately. The mean and standard deviation for SNOT-22 was: males CRSsNP 41.1 (21.0), CRSwNP 41.7 (20.5); females CRSsNP 49.6 (19.7), CRSwNP 49.5 (22.9). In the nasal domain, those with CRSwNP scored more highly than those with CRSsNP; for males 18.1 (8.1) vs. 15.9 (7.9); for females 19.6 (8.0) vs 16.7 (7.5). CONCLUSIONS Patients with CRSwNPs report higher symptom scores in the nasal domain of SNOT-22 than those with CRSsNPs with women in both subgroups reporting higher total scores than men.

Prevalence of asthma, aspirin sensitivity and allergy in chronic rhinosinusitis: data from the UK National Chronic Rhinosinusitis Epidemiology Study

BackgroundChronic rhinosinusitis (CRS) is a common disorder associated with other respiratory tract diseases such as asthma and inhalant allergy. However, the prevalence of these co-morbidities varies considerably in the existing medical literature and by phenotype of CRS studied. The study objective was to identify the prevalence of asthma, inhalant allergy and aspirin sensitivity in CRS patients referred to secondary care and establish any differences between CRS phenotypes.MethodsAll participants were diagnosed in secondary care according to international guidelines and invited to complete a questionnaire including details of co-morbidities and allergies. Data were analysed for differences between controls and CRS participants and between phenotypes using chi-squared tests.ResultsThe final analysis included 1470 study participants: 221 controls, 553 CRS without nasal polyps (CRSsNPs), 651 CRS with nasal polyps (CRSwNPs) and 45 allergic fungal rhinosinusitis (AFRS). The prevalence of asthma was 9.95, 21.16, 46.9 and 73.3% respectively. The prevalence of self-reported confirmed inhalant allergy was 13.1, 20.3, 31.0 and 33.3% respectively; house dust mite allergy was significantly higher in CRSwNPs (16%) compared to CRSsNPs (9%, p < 0.001). The prevalence of self- reported aspirin sensitivity was 2.26, 3.25, 9.61 and 40% respectively. The odds ratio for aspirin sensitivity amongst those with AFRS was 28.8 (CIs 9.9, 83.8) p < 0.001.ConclusionsThe prevalence of asthma and allergy in CRS varies by phenoytype, with CRSwNPs and AFRS having a stronger association with both. Aspirin sensitivity has a highly significant association with AFRS. All of these comorbidities are significantly more prevalent than in non-CRS controls and strengthen the need for a more individualised approach to the combined airway.

Current use of baseline medical treatment in chronic rhinosinusitis: Data from the National Chronic Rhinosinusitis Epidemiology Study (CRES)

According to clinical and comissioning guidelines for chronic rhinosinusitis (CRS), patients being referred to secondary care should have failed primary medical treatment with nasal douching (ND) and intranasal corticosteroids (INCS). The study objectives were to identify the rate of specific medical therapy in CRS patients and establish any differences in medication use, for both CRS and associated medical conditions, between CRS phenotypes.

PANDAS in Otolaryngology

Sir, We would like to bring to the attention of the readership a rare condition known as PANDAS (paediatric autoimmune neuropsychiatric disorder associated with streptococcal infection), which is mostly seen by paediatric psychiatric or neurological physicians. Due to its relationship with the tonsils and an increasing small number of cases reported in the literature of improvement or even cure by tonsillectomy, we feel it warrants further review and discussion. PANDAS syndrome presents predominantly as an acute onset of OCD-like symptoms. Other symptoms include ADHD (attention deficit and hyperactivity disorder)-like behaviour, the child may be emotionally labile, may suffer separation anxiety, poor attention, ‘tic’ development and reduced visual–spatial capabilities. The diagnostic criteria were developed in 1998 by Swedo et al. (Table 1). Symptoms begin between 1 and 2 weeks after the development of a group A streptococcal infection (GAS). The condition can relapse and remit over months to years with flaring of symptoms, before returning to a symptomatic baseline. The latency of symptom development can vary, resulting in the diagnosis requiring thorough history alongside clinical assessment and relevant investigations (presently no definitive serum marker/test is available). Some GAS infections are asymptomatic clouding the already murky area of PANDAS diagnosis, with the pathophysiology of PANDAS already an area of debate. The treatment of PANDAS remains contentious, and common antibiotics targeting GAS infection have been used to improve symptoms during the acute infection; however, the use of prophylactic antibiotics is not recommended, with a trial of 37 subjects revealing no treatment benefit. Possible treatments involving plasmapheresis or intravenous immunoglobulin are being investigated, with mixed results. Relevant to otolaryngologists are the growing number of cases in the literature reporting improvement and in some cases complete resolution of symptoms in those PANDAS patients who have undergone tonsillectomy. A 10 case series from New York reported that only 50% of a cohort of PANDAS patients clinically improved with antibiotics. The same study revealed that all nine children who underwent tonsillectomy had improvement or resolution of their symptoms. However, there is a contradictory case in the literature showing the development of OCD alongside elevated GAS titres 1 week post-tonsillectomy. Presently, there is no clear guidance regarding the use of tonsillectomy to treat PANDAS; however, we feel the otolaryngologist should be aware of this condition especially when presented with a child displaying neuropsychiatric symptoms and recurrent tonsillitis.