Background Olfactory dysfunction is a common symptom of chronic rhinosinusitis (CRS). We previously identified several cytokines potentially linked to smell loss, potentially supporting an inflammatory etiology for CRS‐associated olfactory dysfunction. In the current study we sought to validate patterns of olfactory dysfunction in CRS using hierarchical cluster analysis, machine learning algorithms, and multivariate regression. Methods CRS patients undergoing functional endoscopic sinus surgery were administered the Smell Identification Test (SIT) preoperatively. Mucus was collected from the middle meatus using an absorbent polyurethane sponge and 17 inflammatory mediators were assessed using a multiplexed flow‐cytometric bead assay. Hierarchical cluster analysis was performed to characterize inflammatory patterns and their association with SIT scores. The random forest approach was used to identify cytokines predictive of olfactory function. Results One hundred ten patients were enrolled in the study. Hierarchical cluster analysis identified 5 distinct CRS clusters with statistically significant differences in SIT scores observed between individual clusters ( p < 0.001). A majority of anosmic patients were found in a single cluster, which was additionally characterized by nasal polyposis (100%) and a high incidence of allergic fungal rhinosinusitis (50%) and aspirin‐exacerbated respiratory disease (AERD) (33%). A random forest approach identified a strong association between olfaction and the cytokines interleukin (IL)‐5 and IL‐13. Multivariate modeling identified AERD, computed tomography (CT) score, and IL‐2 as the variables most predictive of olfactory function. Conclusion Olfactory dysfunction is associated with specific CRS endotypes characterized by severe nasal polyposis, tissue eosinophilia, and AERD. Mucus IL‐2 levels, CT score, and AERD were independently associated with smell loss.
“Sinus headache” is a common chief complaint that often leads patients to an otolaryngologist's office. Because facial pain may or may not be sinogenic in origin, the otolaryngologist should be equipped to evaluate and treat or to appropriately refer these patients. Analysis of current data indicates that the majority of patients who present with sinus headaches actually have migraines. Furthermore, the downstream effect of the cytokine cascade initiated in migraine physiology can cause rhinologic symptoms, including rhinorrhea, congestion, and lacrimation, which may also confound diagnosis. Other causes of sinus headache include the following: cluster headaches, Sluder neuralgia, trigeminal neuralgia, myofascial trigger point pain (tension headaches, temporomandibular joint dysfunction), and contact point headaches. The diagnostic dilemma for an otolaryngologist occurs when a patient has facial pain and symptoms that may indicate chronic rhinosinusitis but with nondiagnostic endoscopy. Traditionally, these patients have been primarily managed with empiric antibiotics. An alternative strategy is to first screen these patients with an upfront computed tomography. This algorithm may ultimately decrease cost; avert unnecessary antibiotics prescriptions; and prompt more timely referrals to other, more appropriate, disciplines, such as neurology, dentistry, and/or pain management specialists.
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
Objective To survey patients following sinonasal surgery regarding postoperative pain and opioid use. Study Design Patients were surveyed for 4 days following sinus and/or nasal surgery regarding their pain level and use of prescribed opioids. Setting Four academic medical centers and 1 private practice institution. Subjects Consecutive adult patients undergoing sinonasal surgery. Results A total of 219 subjects met criteria and were included for analysis; 134 patients (61%) took 5 or fewer combination oxycodone (5‐mg) and acetaminophen (325‐mg) tablets in the first 3 postoperative days, and 196 patients (89.5%) took fewer than 15. Fifty‐one patients (23%) consumed no opioid pain medication. Opioid consumption was positively correlated with postoperative pain ( R 2 = 0.2, P <. 01) but was not correlated with the use of acetaminophen ( R 2 = 0.002, P =. 48). No significant difference in postoperative pain or opioid consumption was seen with respect to age, sex, specific procedures performed, postoperative steroids, or smoking history. Current smokers reported higher average pain than nonsmokers ( P <. 001) and also required more postoperative opioids ( P =. 02). Conclusions An evidence‐based approach to postoperative pain control following sinonasal surgery that reduces the number of unused and potentially diverted opioids is needed. The current study suggests that 15 combination oxycodone (5‐mg) and acetaminophen (325‐mg) tablets provide sufficient pain control for 90% of patients in the immediate postoperative period following sinonasal surgery, irrespective of the specific procedures performed, use of acetaminophen, or use of systemic steroids. Smoking status may help surgeons predict which patients will require larger opioid prescriptions.
Olfactory dysfunction is a major symptom reported by patients with chronic rhinosinusitis (CRS). Surgical treatment of this disease requires close surveillance of such dysfunction because of wide ranging implications for safety, quality of life, and impact on the flavor of foods and beverages. This review highlights key findings regarding the influences of endoscopic sinus surgery (ESS) on olfactory function across the unique presentations of CRS. Such findings provide information useful for informing patients of potential complications and for obtaining informed consent prior to surgical intervention. ESS has been shown to improve olfaction across all types of CRS as assessed through quantitative testing and subjective reports. The presence of nasal polyposis (NP) and eosinophilia have been identified as predictors of significant postoperative olfactory improvement. When indicated, judicious partial resection of the middle turbinate may result in improved olfactory function without a risk of long term complication. Careful attention to the olfactory cleft and frontal sinus recess are important in limiting olfactory complications by avoiding indiscriminate disruption of olfactory epithelium. Given the chronic nature of the disease, surveillance of olfactory function in patients with CRS is a lifelong activity that will evolve as emerging technologies become available.
Objectives To study the utilization of balloon catheter dilation (BCD) compared to traditional endoscopic surgery (ESS) in pediatric patients. Study Design Cross‐sectional analysis. Setting Hospital and freestanding ambulatory surgery centers in California, Florida, Maryland, and New York Subjects Patients less than 18 years who underwent BCD(316) or ESS(2346), as identified by CPT codes from the State Ambulatory Surgery Databases 2011. Methods Patient and facility demographics, mean charges, and operating room time were examined using bivariate and multivariate analyses. Results A total of 2662 children underwent surgery, with BCD used in 10.6% of maxillary, 8.4% of sphenoid, and 11.8% of frontal procedures. Adjusted analysis found that children with asthma, allergic rhinitis (AR), GERD, or concomitant adenoidectomy were more likely to have BCD compared to patients without these comorbidities, asthma odds ratio (OR) = 1.94 (95% CI, 1.84‐3.41), AR OR = 1.77 (95% CI, 1.03‐3.07), GERD OR = 2.79 (95% CI,. 59‐4.90), or without adenoidectomy OR = 2.50 (95% CI, 1.84‐3.41). Patients with cystic fibrosis were less likely to have BCD, OR = 0.33 (95% CI, 0.11‐0.95). Median charges for patients undergoing maxillary antrostomy alone by BCD ( P =. 042) or with adenoidectomy ( P <. 001) were approximately $2100 and $4200 greater than the median of patients undergoing those procedures with ESS. However, operating room time was similar ( P =. 81) between patients undergoing maxillary antrostomy, regardless of whether BCD was used, but was longer ( P <. 001) in those undergoing maxillary antrostomy and adenoidectomy when BCD was utilized. Conclusions BCD was used in 11.9% of pediatric sinus surgery and had higher average charges with no decrease in OR time compared to procedures that only utilized ESS. Future research is necessary to evaluate whether BCD may lead to improved outcomes and eventually decreased operating room time for pediatric patients with chronic rhinosinusitis.
