Rhinology Clinic Research Articles

Is SNOT-22 a Reliable Tool During Periods of High Stress? A Retrospective Cohort Study.

To assess the impact of a major crisis, such as the October 7, 2023, terror attack, on SNOT-22 scores, especially the extra-rhinologic subdomains. This retrospective cohort study was conducted at the Rhinology Clinic in a Tertiary University Hospital. Patients who visit our Rhinology Clinic routinely complete the SNOT-22, a widely employed questionnaire designed for evaluating health-related quality of life in individuals with rhinologic conditions. Patients were divided into two groups: 5 weeks before the October 7 terror attack and 5 weeks after. Primary outcomes for analyses included the Sedaghat Subdomain model of the SNOT-22. Descriptive analysis and Welch's t-test were used to compare SNOT-22 subdomain scores between groups. A total of 159 patients completed the SNOT-22 questionnaire, with 60 before and 99 after October 7, 2023. A general decrease in average scores was observed across all subdomains, with a significant decrease in the Nasal subdomain (p = 0.0388). Subgroup analysis showed an increase in the Ear/Facial subdomain in Arabic and the Sleep and Function subdomains in English, though not statistically significant. In sex-based sub-analysis, female patients showed a significant decrease in the Emotions subdomain. Our study was unable to establish a direct link between the terror attack and specific SNOT-22 subdomains. However, the observed trends suggest that SNOT-22 may display variability or unreliability when used during periods of high stress. III Laryngoscope, 2024.

In office sampling of eosinophil peroxidase to diagnose eosinophilic chronic rhinosinusitis.

Practical biomarkers for endotypic characterization of chronic rhinosinusitis (CRS) remain elusive, hindering clinical utility. Eosinophil peroxidase (EPX) is an enzyme released by activated eosinophils. The objective of this study was to evaluate a clinic EPX assay as a marker of eosinophilic CRS. Subjects with and without CRS presenting to a tertiary care rhinology clinic were prospectively enrolled, and nasal cytology brushings were collected from the middle meatus during in-clinic nasal endoscopy. ELISA assay was used to quantify EPX levels, and a customized multiplex immunoassay was used to quantify inflammatory cytokine mediators. Findings were correlated with clinical data. Forty-two subjects were enrolled, including 31 CRS subjects and 11 controls. Median EPX levels were 125.0ng/mL (standard deviation [SD] 1745.8) and 6.5ng/mL (SD 99.0) for CRS group and controls, respectively (p=0.003). EPX levels were associated with history of asthma (p=0.015), allergies (p=0.028), polyps (p=0.0006), smell loss (p=0.006), and systemic eosinophilia or elevated immunoglobulin E (p≤0.0001). Twenty-eight subjects from both the CRS and control groups had prior pathology for comparison, with histologic confirmation of local tissue eosinophilia (>10 eosinophils/hpf) in 11 subjects. This subgroup had a median EPX level of 967.5ng/mL compared to 10.6ng/mL in 17 subjects without local tissue eosinophilia (p=0.0008). EPX levels were positively correlated to interleukin-5 levels (p=0.0005). EPX levels can be measured via well-tolerated in-clinic collection of nasal mucus. EPX levels are associated with clinical markers of type 2 inflammation and tissue eosinophilia and may provide a valuable diagnostic tool to delineate eosinophilic CRS.

Burden of obstructive sleep apnea and CPAP use on patients with chronic rhinosinusitis

ObjectiveTo evaluate the impact of obstructive sleep apnea (OSA) on the quality-of-life (QoL) of patients with chronic rhinosinusitis (CRS). MethodsRetrospective cohort study of all adult patients with CRS presenting to our rhinology clinic between August 2020 and February 2023 was performed. OSA was established based on positive polysomnography. Patients' characteristics, apnea-hypopnea index, comorbidities, endoscopy scores, and SNOT-22 scores were collected. ResultsA total of 513 patients with CRS were included, 127 patients with OSA and 386 without OSA. CRS patients with OSA were older (p < 0.001), had higher BMI (p < 0.001), more likely to be males (p = 0.07), more likely to have asthma (p < 0.001), and more likely to have COPD (p = 0.001). Presence of nasal polyps did not differ between the two groups. Baseline SNOT-22 scores were worse in the OSA cohort (44.4 vs 40.5, p = 0.064) secondary to worse sleep (13.4 vs 11.1; p = 0.002) and psychological (14.2 vs 11.5; p = 0.002) domains. Worse SNOT scores were strongly associated with presence of OSA after adjusting for confounding variables, including age, gender, asthma, allergic rhinitis, nasal septal deviation, and smoking status. ConclusionOSA is an independent negative contributor to the disease specific QoL in patients with CRS. CPAP use does not seem to affect the QoL in CRS patients with OSA. Further research is warranted to explore the impact of OSA in the outcome of medical and surgical treatment of CRS patients.

Sleep dysfunction in aspirin exacerbated respiratory disease: A prospective cohort study

AbstractObjectiveStudies have described sleep dysfunction (SD) in patients with chronic rhinosinusitis (CRS). However, there is a paucity of literature describing sleep dysfunction in the context of aspirin‐exacerbated respiratory disease (AERD). The purpose of this study was to evaluate the prevalence and severity of SD in patients with AERD relative to CRS.MethodsThis study is a prospective cohort study. Patients diagnosed with CRS without polyposis (CRSsNP, n = 206), CRS with nasal polyposis (CRSwNP, n = 38), and AERD (n = 28) were recruited prospectively in academic center rhinology clinic. SD was assessed using the Neuro‐QOL Short Form v1.0‐Sleep Disturbance (sleep‐QOL), for which severe SD is defined as a score &gt;2.0 standard deviations from the normalized mean. Demographic and patient‐reported outcome measures (including SNOT‐22 and PHQ‐2) were collected to adjust for sleep confounders. Comparisons were made between groups using univariate and multivariate analyses.ResultsThe prevalence of severe SD was significantly higher in AERD (57.1%) than in CRSsNP (32.5%) or CRSwNP (34.2%), p = 0.038. After adjusting for sleep confounders, the risk of sleep dysfunction remained higher among patients with AERD (odds ratio [OR] = 2.72 vs. CRSsNP, 95% confidence interval [CI] = 1.18–6.27, p = 0.02; OR = 3.06 vs. CRSwNP, 95% CI = 1.06–8.82, p = 0.04). SNOT‐22 total score and the sleep subdomain showed no correlation with sleep‐QOL score.ConclusionsThe frequency and severity of SD are greater in AERD patients than in patients with CRS with or without nasal polyposis, independent of confounders of sleep quality. While the putative link between AERD and SD remains elusive, this study suggests that SD in AERD may be greater than previously recognized.

Role of Sinonasal Anatomic Variants in Recurrent Acute Rhinosinusitis.

Prior studies evaluating the role of sinonasal anatomic variants with recurrent acute rhinosinusitis (RARS) are limited by inconsistent results. The goal of this study is to evaluate the association between sinonasal anatomic variants and RARS. A 1:2 retrospective case-control study was conducted using patients presenting to the rhinology clinic from August 2020 to January 2023. A total of 60 patients with RARS were compared to 120 control patients. RARS was diagnosed based on the International Consensus Statement on Allergy and Rhinology criteria of four or more independent episodes of acute rhinosinusitis per year with at least one episode documented by objective findings, with complete resolution of the infection in-between episodes. Sinonasal anatomic variants included nasal septal deviation (NSD), concha bullosa (CB), infraorbital (Haller) cells, nasal septal spur in the middle meatus, and frontal sinus cells (supra-agger, supra-agger frontal, and suprabullar frontal cells). Age was similar in RARS and control patients (47.4 ± 16.5 vs. 49.3 ± 14.5, p = 0.432). Both the RARS group and control group were more likely to be female (78.3% vs. 77.5%, p = 0.899). There was no significant association between NSD and RARS compared to the control group (OR = 0.97, p = 0.916), and no significant association between any of the anatomic variants and RARS [infraorbital cells (OR = 0.64, p = 0.167), CB (OR = 0.84, p = 0.596), spur in the middle meatus (OR = 1.28, p = 0.514), supra-agger (OR = 0.88, p = 0.708), supra-agger frontal cells (OR = 0.97, p = 0.939), or suprabullar frontal cells (OR = 1.13, p = 0.766)]. Our findings suggest no association between nasal septal deviation or any of the anatomic variants studied and RARS. 3 Laryngoscope, 134:3489-3492, 2024.

Cognition and saccadic eye movement performance are impaired in chronic rhinosinusitis.

Patients with chronic rhinosinusitis (CRS) can experience cognitive dysfunction. The literature on this topic mostly reflects patient-reported measurements. Our goal was to assess cognitive function in patients with CRS using objective measures, including saccadic eye movements-a behavioral response reflecting cognitive and sensory information integration that is often compromised in conditions with impaired cognition. Participants (N=24 with CRS, N=23 non-CRS healthy controls) enrolled from rhinology clinic underwent sinonasal evaluation, quality of life assessment (Sino-nasal Outcome Test 22 [SNOT-22]), and cognitive assessment with the Neuro-QOL Cognitive Function-Short Form, the Montreal Cognitive Assessment (MoCA), and recording of eye movements using video-oculography. Participants with CRS were more likely to report cognitive dysfunction (Neuro-QOL; 45.8%vs. 8.7%; p=0.005) and demonstrate mild or greater cognitive impairment (MoCA; 41.7%vs. 8.7%; p=0.005) than controls. Additionally, participants with CRS performed worse on the MoCA overall and within the executive functioning and memory domains (all p<0.05) and on the anti-saccade (p=0.014) and delay saccade (p=0.044) eye movement tasks. Poorer performance on the MoCA (r=-0.422; p=0.003) and the anti-saccade (r=-0.347; p=0.017) and delay saccade (r=-0.419; p=0.004) eye movement tasks correlated with worse CRS severity according to SNOT-22 scores. This study is the first to utilize objective eye movement assessments in addition to researcher-administered cognitive testing in patients with CRS. These patients demonstrated a high prevalence of cognitive dysfunction, most notably within executive functioning and memory domains, with the degree of dysfunction correlating with the severity of CRS.

Predictors of Non-Rhinogenic Facial Pain or Pressure in Otolaryngology Clinic.

Identify demographic and clinical characteristics that may help differentiate non-rhinogenic facial pain or pressure (NRFP) from sinusitis. Retrospective single-institution study. Tertiary Care Center Rhinology Clinic. All patients presenting with a complaint of facial pain or pressure over a 3-year period were included. Patients were categorized into either NRFP or sinusitis groups based on computed tomographyimaging and nasal endoscopy. Data pertaining to demographics, history, and SNOT-22 questionnaire domains were compared via univariate analysis as well as logistic regression with backwards variable selection. A total of 296 patients met inclusion criteria, of which 128 had NRFP and 168 had sinusitis. A significantly greater percentage of patients in the NRFP group were women of childbearing age (40.6% vs 28.0%, P = .02). Backwards variable selection resulted in a model with four variables predicting a diagnosis of NRFP-female sex (odds ratio [OR] = 2.998, P < .0001), no history of prior sinonasal surgery (OR = 0.340 for history vs no history, P < .01), low nasal domain score (OR = 0.551, P < .0001), and high ear/facial domain score (OR = 1.453, P < .01). Accurately identifying patients with NRFP at initial presentation based on history would help direct patients to the appropriate care pathway and prevent ineffective treatments such as antibiotics and sinus procedures. Our findings suggest that the suspicion for NRFP should be higher in women of child-bearing age as well as patients with greater ear/facial symptoms or lesser nasal symptoms.

Validation and cross-cultural adaptation of the Arabic version of the self-reported mini olfactory questionnaire (Self-MOQ).

A simple self-assessment screening questionnaire for olfactory dysfunction is direly needed in Rhinology practice, and this questionnaire should be accessible to affected individuals. The self-reported mini olfactory questionnaire (Self-MOQ), constructed to fill this gap, could be an important tool, especially in the era of telemedicine. The aim of this study was to assess the validity and reliability of the Arabic version of the self-reported mini olfactory questionnaire (Self-MOQ) in patients with olfactory dysfunction. This cross-sectional study included all adult patients who visited a rhinology clinic between January and June 2023 with a complaint of olfactory dysfunction and a control group. The participants completed a questionnaire that included items on demographics, risk factors of olfactory dysfunction, the olfaction VAS, SNOT-22, and Arabic Self-MOQ. The Self-MOQ was forward- and back-translated by qualified professional translators familiar with American English and Arabic.The reliability of the Arabic Self-MOQ was evaluated using Cronbach's α. The test-retest reliability was assessed by estimating the intraclass correlation coefficient (ICC) for the total Arabic Self-MOQ score and the individual items. The discriminative ability was examined by comparing the scores of the case and control groups. The construct validity was assessed by comparing the Arabic Self-MOQ to the olfaction VAS. The study sample included 307 respondents (196 cases and 111 controls; 34 undertook the retest). The Cronbach's α coefficients were 0.92 (total Self-MOQ) and considered excellent. The ICC for the total Self-MOQ score was 0.87 (95% CI: 0.757, 0.933; p < .001), which indicated good test-retest reliability. Strong correlations were observed between the Self-MOQ items and VAS scores (r = 0.732, p < .001), (r = 0.689, p < .001). The current investigation showed the Arabic version of the Self-MOQ to be a reliable tool for olfactory dysfunction screening.

Decreases in Rhinology Care Utilization by People with Cystic Fibrosis on Highly Effective Modulator Therapy.

Many people with cystic fibrosis (PwCF) have chronic rhinosinusitis (CRS). CRS requires additional management beyond that of pulmonary disease and leads to increased utilization of healthcare resources. Elexacaftor/tezacaftor/ivacaftor (ETI) is a highly effective modulator therapy that has been shown to improve CRS in PwCF. However, the impact of ETI on rhinologic healthcare utilization is understudied. To compare rates of rhinologic healthcare utilization and procedures among PwCF prior to and after initiating ETI therapy. A single-center, cohort study investigating adult PwCF was performed in January 2023. Demographics, clinical characteristics, and data related to CF treatment were retrospectively abstracted. Characteristics of the cohort were compared over 2 periods: the 12-months prior to ETI initiation and the 12-months after ETI initiation. Post-ETI data were linearly extrapolated if a subject had not yet completed the full 12 months of ETI. Paired t-testing, Wilcoxon signed rank testing, and regression analysis were performed. Of 126 PwCF, 98 (77.8%) were on ETI therapy and 35 (27.7%) were both on ETI and concurrently followed by the rhinology service (ETI-ENT). Rhinology clinic visits (P = .007) and frequency of obtaining nasal cultures (P = .046) decreased for the ETI-ENT cohort after initiating ETI treatment. There were no significant changes in the number of endoscopic sinus surgeries (P = .452) performed. Beyond ETI use, regression analysis did not identify any factors associated with changes in utilization. Aspects of rhinology healthcare utilization by PwCF decreased after initiation of ETI therapy. Additional studies are needed to determine rhinologic healthcare requirements for PwCF who remain on ETI for the long-term and to evaluate larger cohorts of PwCF on ETI.

The Rate and Predictors of Allergic Fungal Rhinosinusitis Recurrence Post-sinus Surgery: A Retrospective Cohort Study.

Objectives Chronic rhinosinusitis (CRS) is the persistent inflammation of the mucosal lining of the paranasal sinuses (PNS). By definition, the inflammatory process persists beyond 12 weeks. One of its subtypes is allergic fungal rhinosinusitis (AFRS), which has a high risk of recurrence, leading to revision surgery. This study aimed to establish the predictive factors for the recurrence of AFRS in post-sinus surgery patients. Methods This single-center retrospective study was conducted in Al-Noor Specialist Hospital, Makkah, Saudi Arabia. The charts of patients with AFRS who underwent surgery in our rhinology clinic between 2000 and 2020 were reviewed. Results Among the 116 patients included in this study, approximately half (53%) were female, with a median age of 24.5 years. Thirty-nine (33.6%) patients had recurrence post-sinus surgery, with 33.3% occurring within six months of follow-up. The results showed that patients with coexisting bronchial asthma were three times more likely to experience recurrence (adjusted odds ratio {AOR}, 3.43; confidence interval {CI}, 1.35-8.71), patients with uncorrected deviated nasal septum (DNS) were three times more likely to experience symptoms again following surgery (AOR, 3.70; CI, 1.14-12.02), and patients who presented with concomitant sinusheadaches are 66% less likely to experience recurrence (AOR, 0.34; CI, 0.13-0.86). Conclusion The results showed that 33.62% of patients experienced recurrence following surgery. Bronchial asthma and DNS were strongly associated with recurrence; however, their presence does not always imply the need for additional surgery.

Clinical and imaging features of ethmomaxillary sinus compared to Haller's cell.

Understanding the anatomy of the paranasal sinuses and their variations is essential to achieving safe and effective endoscopic sinus surgery. The ethmomaxillary sinus (EMS) is a relatively under-researched anatomical variation.This study investigated the prevalence, clinical features, and effect of EMS on the maxillary sinus in comparison with Haller's cells. Patients who visited the Rhinology Clinic at our hospital for rhinologic symptoms between January 2020 and December 2020. Computed tomography (CT) scans of paranasal sinuses were obtained at 1mm-section thickness. Using CT scans, we investigated the clinical features of EMS, measured maxillary sinus volume, and analyzed the presence of maxillary sinusitis. EMS was observed in 26 of the 250 patients (10.4%). The male-to-female ratio was equal. The age ranged from 18 to 83years (mean age, 56.3). Of the patients with EMS, 65.4% were unilateral and 34.6% were bilateral. The prevalence of Haller's cells was similar to that in EMS (10.8%). In the analysis of patients with unilateral EMS, the EMS side was found to have a significantly reduced maxillary sinus volume compared to the opposite side, whereas the difference was not significant in Haller's cells. There was no significant relationship between EMS or Haller's cells and maxillary sinusitis. EMS can significantly affect maxillary sinus volume. Therefore, surgeons should thoroughly review PNS CT scans before paranasal sinus surgery to determine the presence and features of EMS.

Clinical features and ICHD headache diagnoses for patients with prominent craniofacial pain referred by a rhinologist to headache specialists (P11-12.003)

<h3>Objective:</h3> To describe the clinical features and final headache diagnoses of patients with prominent craniofacial pain who were referred by a rhinologist to a headache specialist. <h3>Background:</h3> Many patients with craniofacial pain are misdiagnosed with “sinus headache” and are often referred to otolaryngologists for evaluation of sinus disease. However, the benefit of collaboration between rhinologists and headache specialists for evaluation of patients with putative sinus headache has not been studied. <h3>Design/Methods:</h3> We conducted a single-center retrospective case series of patients who saw a rhinologist for craniofacial pain and were subsequently referred to a headache specialist for presumed non-sinogenic craniofacial pain between January 2016 and March 2019. SNOT-22 (Sino-Nasal Outcome Test-22 questionnaire) score, ICHD (International Classification of Headache Disorders) diagnosis, patient characteristics, endoscopy results, and headache characteristics were assessed. <h3>Results:</h3> Of 98 patients, 73 (74.5%) were female, the mean age was 50.9 years, and the mean SNOT-22 score was 48.6. Nasal endoscopy performed in the rhinology clinic revealed normal results in 90 (92.7 %) patients, edema was noted in 4 (5.2%) patients, and mucopurulence in 2 (2%) patients. Most patients described their pain as frontal or frontal-maxillary, dull or throbbing, and moderate to severe. Migraine (episodic and chronic) was the most common final diagnosis in 48 (49.0 %) patients, and the second most common diagnosis was tension-type headache in 17 (17.3%) patients. <h3>Conclusions:</h3> Patients referred from a rhinologist to a headache specialist for non-sinogenic craniofacial pain are likely to have a final diagnosis of a primary headache disorder, specifically migraine or tension-type headache, rather than a true sinus-related disorder. Collaboration between specialists may improve diagnostic accuracy and outcomes for patients with craniofacial pain that may be confused for sinus headache. <b>Disclosure:</b> Dr. Alayyas has nothing to disclose. Ms. Singh has nothing to disclose. Mr. Saleem has nothing to disclose. John Craig has received personal compensation in the range of $0-$499 for serving as a Consultant for Optinose USA, Inc. Dr. Ali has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Ebsco.

Clinical outcomes of dupilumab therapy in chronic rhinosinusitis with nasal polyps in a Canadian tertiary care rhinology practice

BackgroundIn 2020, dupilumab became the first monoclonal antibody therapy to be approved by Health Canada for the treatment of chronic rhinosinusitis with nasal polyps (CRSwNP). The primary aim of this study was to characterize the outcomes in an initial cohort of patients with CRSwNP who have undergone dupilumab therapy.MethodsA retrospective study was conducted of patients with CRSwNP who were treated with dupilumab. Demographic information, comorbidities, number of previous surgeries, and insurance information were collected. The primary outcome were changes in the sinonasal outcome test (SNOT-22) scores from baseline to timepoints after receiving dupilumab.ResultsForty-eight patients were considered for dupilumab therapy, and 27 (56%) received coverage or were able to fund the medication independently. Patients waited an average of 3.6 months to obtain access to the medication. The mean age of the patients was 43. Forty-one percent (11/27) of patients had aspirin exacerbated respiratory disease, and 96% (26/27) had a diagnosis of asthma. The mean length of time on dupilumab was 12.1 months. The baseline SNOT-22 score was 60.6. The mean decrease at 1 month, 3 months, 6 months, and 12 months after starting dupilumab was 8.8, 26.5, 42.8, and 33.8, respectively. There were no serious adverse events.ConclusionPatients treated with dupilumab in a Canadian tertiary care rhinology clinic demonstrated substantial clinical improvement as measured by disease-specific sinonasal outcomes. Further studies are needed to determine the longer-term effectiveness and adverse event profile of this novel therapy.

Endoscopic appearance of duplicated middle turbinate, case series and literature review.

Duplication of the middle turbinate is an extremely rare condition encountered in rhinology clinic. Knowledge and awareness of the nasal turbinates' variations are important to perform a safe endoscopic surgery and evaluate patients with inflammatory sinus diseases. Case series of two patients who visited rhinology clinic in academic university hospital. Case 1: presented with 6-month history of nasal blockage. Nasal endoscopy revealed bilateral duplication of the middle nasal turbinates. Computed tomography scans showed bilateral medially curved and anteriorly folded uncinate process, and right middle turbinate concha bullosa and its superior end of the middle turbinate was turned medially. Case 2: A 29-year-old gentleman presented with nasal obstruction mainly to the left side for several years. Nasal endoscopy showed bifid right middle turbinate and severe deviated nasal septum to the left. Upon imaging, a sinus computed tomography scan demonstrated a duplication of the right middle turbinates in the form of two middle nasal concha. Different rare anatomical variations can occur at different points during the embryological development. These rare variations include double middle turbinate, accessory middle turbinate, secondary middle turbinate, and bifid inferior turbinate. The appearance of double middle turbinate can be encountered in rhinology clinic only 2% of the time. Upon reviewing the literature, only few case reports were found regarding the double middle turbinate. A double middle turbinate has important clinical implications. Anatomical variation may lead to narrowing in the middle meatus which makes the patient vulnerable to sinusitis or maybe associated with secondary symptoms. We report rare cases of middle turbinate duplication. Awareness of the nasal turbinates' variations is important for detection and management of inflammatory sinus diseases. Further studies are needed to identify the association of other pathology.

Skin Prick Test Reactivity to Common Allergens among Allergic Rhinitis Patients in Kocaeli Province, Turkey

Objective: The identification of the most common aeroallergens causing allergic rhinitis (AR) in a specific geographic area is important in the diagnosis and treatment of AR. This study evaluates the prevalence of sensitivity to aeroallergens among patients with AR who live in Kocaeli province, Turkey. Methods: This cross-sectional, descriptive study included a retrospective review of skin prick test (SPT) results from patients with suspected AR who were examined at a tertiary hospital rhinology clinic. Results: The SPT results of 85 patients with an AR diagnosis were included in this study. House dust mites (HDM) had the highest frequency of positive test responses (57.6%), followed by tree pollen (40.0%), grass pollen (36.5%), weed pollen (32.9%), cockroach (18.8%), animal dander (14.1%), and mold (11.8%). The majority of the AR patients were polysensitized (57.6%), and the most common allergens in polysensitized patients were tree pollen (61.2%), grass pollen (57.1%), and HDM (55.1%), respectively. The strongest single allergen in monosensitized subjects was HDM, with a rate of 61.1%. Conclusion: The most prevalent allergen was HDM among AR patients in the Kocaeli region, followed by tree pollen and grass pollen. Polisensitization occurs more frequently than monosensitization. These allergens should be prioritized in the diagnosis and treatment of allergic rhinitis in Kocaeli region patients.

Telephone versus face-to-face clinics for the management of new rhinology referrals: a retrospective cohort study.

This study aimed to compare outcomes of telephone and face-to-face consultations for new rhinology referrals and discuss the wider use of telemedicine in rhinology. This was a retrospective cohort study of new rhinology referrals seen in either a telephone or face-to-face clinic. Primary outcome was the proportion of patients given a definitive outcome at initial appointment (discharged or added to waiting list) versus those requiring follow up. A total of 137 patients (70 telephone, 67 face-to-face) were included. A total of 45 of 67 patients (67 per cent) undergoing a face-to-face consultation received a definitive outcome following initial review, versus 11 of 70 (16 per cent) telephone patients. Of 70 telephone patients 57 (81 per cent) were followed up face-to-face for examination. The role of telephone clinics in the assessment of new rhinology referrals is currently limited by the lack of clinical examination. Further research on developing remote assessment pathways that incorporate asynchronous review of recorded examinations are needed before telemedicine can become established within the rhinology clinic.

Burn Pit Exposure Is Associated With Increased Sinonasal Disease.

The aim of this study was to determine whether self-reported burn pit exposure is associated with increased subjective and objective sinus disease. A cross-sectional study was performed evaluating consecutive adult patients presenting to a US Military rhinology clinic. Demographics, medical histories, sinonasal quality-of-life scores, and nasal endoscopy examinations were obtained. Participants were divided into three cohorts based on self-reported exposure histories and outcomes compared. One hundred eighty-six patients met the inclusion criteria, the majority of whom were male. Patients with burn pit exposure had worse Sinonasal Outcome Test-22 scores (49.9) compared with those deployed without burn pit exposure (31.8) or never deployed (31.5). Endoscopic findings demonstrated worse disease within those exposed (Lund-Kennedy score, 3.3) compared with the other cohorts (1.8 and 1.7, respectively). These novel findings suggest that deployment-related burn pit exposure is associated with increased subjective and objective sinus disease.

ISOLATED CARTILAGINOUS PERFORATION IN EHLERS-DANLOS SYNDROME: A FEATURE OF THE DISEASE?

TYPE: Case Report TOPIC: Allergy and Airway INTRODUCTION: Ehlers Danlos syndrome (EDS) is a genetic connecting tissue disorder affecting collagen formation and function. It can affect every organ system in the body. Clinically it manifests with skin hyper-elasticity, joint hypermobility and atrophic scarring [1,2]. EDS is associated with distinctive facial features, including epicanthal folds, palpebral ptosis, sunken eyes, hypo/hypertelorism, infraorbital creases, hypoplastic auricular lobe, retrognathia and anteverted nostrils [5]. Although EDS is known to be associated with septal deviation [6], there is little further description in the literature with regards to this. CASE PRESENTATION: A 55 year old female patient with known EDS presented to rhinology clinic with symptoms of left sided nasal obstruction. On clinical examination, she had a deviated septum to the left and nasal polyps. There was no history of trauma and she had tried Sterimar and steroid nasal sprays with no symptomatic benefit. During the septoplasty procedure, it was found that the patient had an isolated cartilaginous septal perforation, with an intact covering of mucoperichondrium on either side of the septum (Figure 1). DISCUSSION: EDS is mostly associated with mutations that affect type I, type III and type V collagen [3] , so why EDS is associated with septal deviation is unclear. CONCLUSIONS: To the best of the authors’ knowledge, there are no reports in the literature with regards to septal perforation in EDS patients, which makes the case more interesting as to whether the septal perforation in this case is an incidental finding or part of EDS that is yet poorly understood. DISCLOSURE: Nothing to declare. KEYWORD: ehlers-danlos

Mental health burden of empty nose syndrome compared to chronic rhinosinusitis and chronic rhinitis.

Empty nose syndrome (ENS) is characterized by the paradoxical perception of nasal obstruction despite patent sinonasal anatomy after surgery. We investigated the relationship between ENS, and anxiety, depression, obsessive-compulsive disorder, and somatic symptom disorder (SSD) compared to individuals with chronic rhinitis (CR) and chronic rhinosinusitis (CRS). This cross-sectional survey study compared ENS and CR and CRS patients. A total of 116 patients participated: 58 ENS patients from digital support groups, and 58 CRS and CR patients from tertiary rhinology clinics. Study participants completed four validated surveys: (1) Empty Nose Syndrome 6-Item Questionnaire, (2) Rhinosinusitis Disability Index (RSDI), (3) Obsessive Compulsive Inventory - Revised (OCI-R), and (4) PRIME MD Patient Health Questionnaire (PHQ). ENS patients exhibited a mean RSDI of 78.6, 95% confidence interval [CI] 72.8-84.5, compared to 25.2, 95% CI 18.6-31.8 for CRS/CR patients (p<0.0001). This difference was seen across all subdomains. Using the PHQ, 53% of ENS patients met diagnostic thresholds for SSD compared to 14% of CRS patients (p<0.0001). In relation to obsessive compulsive disorder (OCD), 18.37% of ENS patients compared to 8.62% of CRS/CR patients scored above the diagnostic threshold (>21) on the OCI-R questionnaire (p=0.159). ENS patients had diminished sinonasal quality of life and a higher prevalence of comorbid anxiety and depression, compared to CR and CRS. ENS patients were more likely to exceed thresholds for OCD and SSD compared to controls. Future studies are needed to assess the role of SSD in ENS to help optimize treatment for these complex patients.

A Prospective Analysis of Systemic and Local Aeroallergen Sensitivity in Central Compartment Atopic Disease.

To compare systemic allergen sensitivity and local allergen sensitivity in the sinonasal tissue of patients with a recently identified subtype of chronic rhinosinusitis strongly associated with allergy: central compartment atopic disease (CCAD). Prospective cohort study. Academic tertiary care rhinology clinic. Fifteen participants with endoscopic and radiographic evidence of CCAD underwent systemic allergy testing with skin testing and measurement of serum specific immunoglobulin E (sIgE) to 15 regionally common aeroallergens. Local allergen sensitivity was determined by measuring sIgE to these same 15 allergens in their sinonasal tissue. sIgE testing was performed by ImmunoCAP assay. Of the 15 participants, 14 were sensitive to at least 1 allergen locally in the central compartment and systemically on skin or serum testing. Among all participants, 4 were sensitive to allergens on central compartment sIgE testing that they were not sensitive to on skin and serum sIgE testing (range, 1-8 discordant allergens). Comparisons between local and systemic aeroallergen sensitivity results showed statistically significant correlations (P < .05) ranging from weak to strong. Systemic allergy testing is recommended in the initial workup for CCAD. Local allergen sensitivities may be present in a subset of patients with CCAD. Further study of the clinical significance of these sensitivities should be undertaken in CCAD, with evaluation of the role of medical therapies and allergen immunotherapy in the treatment of CCAD.