Background Chronic rhinosinusitis (CRS) has been identified as a high‐priority disease category for quality improvement. To this end, this study aimed to develop CRS‐specific quality indicators (QIs) to evaluate diagnosis and management that relieves patient discomfort, improves quality of life, and prevents complications. Methods A guideline‐based approach, proposed in 2012 by Kötter et al. was used to develop QIs for CRS. Candidate indicators (CIs) were extracted from 3 practice guidelines and 1 international consensus statement on the diagnosis and management of CRS. Guidelines were evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. Each CI and its supporting evidence was summarized and reviewed by an expert panel based on validity, reliability, and feasibility of measurement. Final QIs were selected from CIs utilizing the modified RAND Corporation–University of California, Los Angeles (RAND/UCLA) appropriateness methodology. Results Thirty‐nine CIs were identified after literature review and evaluated by our panel. Of these, 9 CIs reached consensus as being appropriate QIs, with 4 requiring additional discussion. After a second round of evaluations, the panel selected 9 QIs as appropriate measures of high‐quality care. Conclusion This study proposes 9 QIs for the diagnosis and management of patients with CRS. These QIs can serve multiple purposes, including documenting the quality of care; comparing institutions and providers; prioritizing quality improvement initiatives; supporting accountability, regulation, and accreditation; and determining pay‐for‐performance initiatives.
Les opioïdes jouent un rôle important dans le traitement de la douleur de nombreux patients, mais sont de plus en plus associés au trouble de l’utilisation de substances et à des effets indésirables en Amérique du Nord. Dans cette étude de cas, nous décrivons le premier cas canadien de séquelles significatives intranasales et pharyngiques suite à l’utilisation d’opioïdes intranasaux. Les approches de diagnostic et de traitement sont ensuite décrites. Chez les patients présentant des représentations atypiques, les lésions tissulaires induites par les opioïdes intranasaux devraient être envisagées dans le diagnostic différentiel des lésions tumorales otolaryngologiques. Ce cas souligne l’importance de pouvoir reconnaître les complications otolaryngologiques de la mauvaise utilisation des opioïdes intranasaux et traiter ainsi de manière appropriée en utilisant une approche multidisciplinaire. ABSTRACT Opioids play an important part in the pain management of many patients, but are increasingly associated with substance use disorder and adverse events in North America. In this case report, we describe the first noted Canadian case of significant intranasal and pharyngeal sequelae of intranasal opioid use. Diagnostic and treatment approaches are then described. In patients with atypical presentations, intranasal opioid-induced tissue damage should be considered in the differential diagnosis of otolaryngologic tissue damage. This case highlights the importance of being able to recognize the otolaryngologic complications of intranasal opioid misuse and thereby appropriately treat using a multidisciplinary approach.
Objectives/Hypothesis Sinonasal diseases are often treated with topical agents administered through various application techniques, but few prior studies have examined their distribution to the olfactory mucosa. The purpose of this study was to compare the distribution of nasal irrigations to sprays within the olfactory cleft. Study Design Human cadaveric study. Methods Eight cadaveric heads, providing a total of 15 nasal sides, underwent treatment with methylene blue solution. Application utilized a pressurized spray device followed by an irrigation squeeze bottle, both used according to manufacturer instructions. Videos and images from six standardized anatomical positions were recorded by rigid nasal endoscopy prior to and following each method of agent delivery. Using the acquired images, three reviewers blinded to the means of application scored the approximate surface area stained. An image‐analysis program was additionally calibrated and used to measure pixel intensity in order to quantify surface delivery of methylene blue. Results Based on both blinded reviewer ratings and image pixel intensity measurements, irrigations demonstrated a greater extent and intensity of staining than sprays within the sphenoethmoid recess, superior turbinate, and superior olfactory cleft (all P < 0.05). Sprays and irrigations, however, were comparable in the extent of staining at the nasal vestibule ( P > 0.05), inferior turbinate ( P = 0.04), and middle turbinate ( P > 0.05). Conclusions Compared to sprays, irrigations provide a more effective method of delivering topical agents to the posterior and superior aspects of the nasal cavity. The thorough distribution of irrigations has important clinical implications for improving the delivery of therapeutic agents to the olfactory mucosa. Level of Evidence N/A. Laryngoscope , 123:2950–2957, 2013
Background This is the first case to our knowledge of a serious adverse event following the Epley maneuver, which is the treatment of choice for benign paroxysmal positional vertigo (BPPV), the most common vestibular disorder in adults. Case presentation A 77 year old female presented for outpatient evaluation of vertigo at a tertiary otolaryngology clinic. She was found to have BPPV clinically, and elected to have a particle repositioning maneuver (Epley maneuver) performed in clinic. Immediately following Epley maneuver, she had severe nausea and vomiting, with evolving visual changes. A CT angiogram of the brain was performed urgently through the emergency department and demonstrated an acute intraparenchymal hemorrhage in the occipital lobe. After medical stabilization and rehabilitation, the patient continues to have a permanent visual field deficit. Conclusion The Epley maneuver is safe and effective, and there are no prior reports of serious adverse events associated with its use. This case, in which a patient experienced a hemorrhagic stroke after undergoing the Epley maneuver, is the first and sole case in the medical literature of an Epley-associated serious adverse event. The indirect causation and extreme rarity of this event do not warrant any change to patterns of practice.
Abstract Objectives/Hypothesis: A possible medical treatment for sensorineural hearing loss using brain‐derived nerve growth factor (BDNF) was explored. The hypothesis is that direct intracochlear application of BDNF will result in improved hearing. Study Design: Animal research study. Methods: Significant hearing loss was created using cisplatin in 11 guinea pigs. One month later, bilateral cochleostomies were performed placing 0.05 μg of BDNF in one cochlea of each animal prior to plugging with connective tissue. The other cochlea served as a control. Auditory brain‐stem response (ABR) testing was then carried out for three months at 6,000, 8,000, 12,000, and 24,000 Hz. Results: ABR thresholds were better in the treated ear for all frequencies. Threshold differences were statistically significantly better two months after treatment (general linear model, repeated measures P = .045). Conclusions: Intracochlear application of BDNF may prevent hearing loss. Laryngoscope, 2009
Background Sleep-disordered breathing (SDB) is a spectrum of airway collapse, ranging from primary snoring to profound obstructive sleep apnea (OSA). Studies have shown an association between impaired nasal breathing and SDB; consequently, treatments of nasal obstruction are often used in an attempt to improve disease severity. The authors performed a review of the literature to determine the impact of nasal obstruction and the effectiveness of nonsurgical and surgical interventions on SDB. Methods Relevant literature up to 2012 on the association between nasal obstruction and SDB and effectiveness of nonsurgical and surgical treatment of the nose in SDB were reviewed. Results The literature is mostly limited to uncontrolled case series in which patient groups, interventions, disease definitions, and outcome measures are not standardized. Nasal medications, including intranasal steroids and nasal decongestants, have not been shown to improve either snoring or OSA. Nasal dilators have no impact on OSA but may improve snoring. Surgery for nasal obstruction does not improve objective indicators of SDB but can improve subjective elements of disease, such as snoring, sleepiness, and quality of life. Nasal surgery can facilitate continuous positive airway pressure use in cases where nasal obstruction is the factor limiting compliance. Conclusion Nasal obstruction plays a modulating, but not causative, role in SDB. Nasal interventions may improve subjective aspects of snoring and OSA but do not improve objective indicators of disease. Standardization of methods and higher evidence level studies will further clarify the benefit of nasal interventions in the treatment of SDB.
Inguinal hernia is a common condition, and the hernial contents may vary. We describe a rare case of an incarcerated uterine fibroid diagnosed in a pregnant woman. The treatment was operative, and we were able to successfully reduce the fibroid and close the hernia.
Objective To evaluate if molecular markers of eosinophilia in olfactory‐enriched mucosa are associated with olfactory dysfunction. Study Design Cross‐sectional study of tissue biopsies from 99 patients, and an additional 30 patients who underwent prospective olfactory testing prior to sinonasal procedures. Methods Tissue biopsies were processed for analysis of inflammatory markers using quantitative real time polymerase chain reaction (qRT‐PCR). Ipsilateral olfactory performance was assessed using the Sniffin' Sticks (Burghart, Wedel, Germany) threshold component and the University of Pennsylvania Smell Identification Test (Sensonics, Haddon Heights, NJ). Age‐adjusted data was correlated with inflammatory marker expression and clinical measures of obstruction from computed tomography and endoscopy. Results Gene expression of the eosinophil marker CLC (Charcot Leyden crystal protein) was elevated in superior turbinate (ST) tissue in chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP) compared to ST and inferior turbinate tissue in CRS without nasal polyps (CRSsNP) and control patients (all P < 0.001, respectively). CLC in ST tissue was correlated with IL‐5 and eotaxin‐1 expression (all P < 0.001; P = 0.65, and 0.49, respectively). CLC expression was strongly correlated with eosinophilic cationic protein levels ( P < 0.001; r = −0.76), and ST CLC expression was inversely related to olfactory threshold ( P = 0.002, r = −0.57) and discrimination scores ( P = 0.05, r = −0.42). In multiple linear regression of CLC gene expression, polyp status, and radiographic and endoscopic findings with olfactory threshold, CLC was the only significantly correlated variable ( P < 0.05). Conclusion Markers of eosinophils are elevated in the ST of patients with CRSwNP and correlate with olfactory loss. These findings support the hypothesis that olfactory dysfunction in CRS correlates local eosinophil influx into the olfactory cleft. Level of Evidence NA. Laryngoscope , 127:2210–2218, 2017
