Educational Pearl
Rhinosinusitis is inflammation of the sinuses and is one of the most common health complaints leading to physician visits in the United States. It is also one of the leading causes of antibiotic prescriptions. Sinusitis can affect any of the sinuses: frontal, maxillary, sphenoid, and ethmoid. There are four classifications:
Acute: Sudden onset, lasting less than 4 weeks, with complete resolution.
Subacute: Lasting between 4-12 weeks
Recurrent acute: Four or more episodes of acute sinusitis, each lasting at least 7 days, within one year.
Chronic: Persistent symptoms lasting longer than 12 weeks.
Etiology: Sinusitis is usually caused by a combination of environmental factors and/or host atopy (predisposition to allergic reactions). Acute sinusitis is most commonly viral, with around 90% of common colds involving an element of viral sinusitis. It can also be triggered by allergens, irritants (such as animal dander, air pollution, smoke, and dust), fungi, and bacteria. Bacterial sinusitis often occurs secondary to a viral infection and is characterized by worsening symptoms after 5 days or persistent symptoms after 10 days despite treatment.
Pathophysiology: Sinusitis occurs due to edema and inflammation of the nasal lining. Thickened mucus obstructs the paranasal sinuses, leading to secondary bacterial overgrowth
Presenting Symptoms:
Facial pain or pressure
Facial congestion or fullness
Nasal obstruction
Nasal or postnasal purulence
Hyposmia (reduced sense of smell)
Fever
Other accompanying symptoms may include headache, halitosis (bad breath), fatigue, malaise, dental pain, cough, or otalgia (ear pain)
Diagnosis: Sinusitis is often a clinical diagnosis based on patient history and physical exam. Common findings on physical exam include:
Facial swelling
Periorbital edema
Cervical adenopathy
Mucosal edema, crusting, purulence, and polyps on anterior rhinoscopy
Sinus opacification, air-fluid levels, mucosal thickening, and sinus wall displacement on CT imaging
Treatment & Management:
Humidification, saline irrigation, hydration, warm compresses.
Antibiotic (amoxicillin +/- clavulanate) use in patients who have suspected bacterial cases if symptoms worsen after 5-7 days or persist for 10 days.
Corticosteroids
Functional endoscopic sinus surgery (FESS) is indicated in patients with extensive disease and/or structural abnormalities.
Monoclonal antibodies (dupilumab, mepolizumab, and omalizumab) used in refractory cases.
Further Reading:
Statpearls: Acute Sinusitis
Otolaryngology - Head and Neck SurgeryWritten by Camryn Marshall,
Charles E. Schmidt College of Medicine, Florida Atlantic University
Question of the Week
A 42-year-old man presents to the clinic with a 6-month history of recurrent ear infections in the right ear, accompanied by persistent ear drainage and hearing loss. Despite multiple courses of antibiotics, his symptoms have not improved. On physical exam, there is foul-smelling purulent discharge from the right ear, and otoscopy reveals a retraction pocket in the superior part of the tympanic membrane with visible granulation tissue and debris. Audiometry shows a conductive hearing loss in the affected ear. A CT scan of the temporal bone shows erosion of the ossicles and the bony margins of the middle ear.
Which of the following complications is most likely if the underlying condition remains untreated?
A) Meningitis
B) Sudden sensorineural hearing loss
C) Facial nerve paralysis
D) Otosclerosis
E) Vestibular schwannoma
Answer at end of issue
Question by Adriana Báez Berríos
Icahn School of Medicine at Mount Sinai
November 20th, 2024
Issue #79
Our faculty content reviewers have been instrumental in ensuring that we continue to share high-quality content.
We thank them for their contributions to the Auricle!
Facial Plastic and Reconstructive Surgery
Dr. Jacob Dey, MD
Mayo Clinic
Head and Neck Surgery
Dr. Akina Tamaki, MD
University Hospitals-Cleveland Medical Center
Laryngology
Dr. Inna Husain, MD
Community Healthcare System, Indiana
Otology/Neurotology
Dr. Emily Stucken, MD
University of Michigan
Pediatric Otolaryngology
Dr. Michele Carr, MD, DDS, MEd, PhD
University at Buffalo, Jacobs School of Medicine and Biomedical Sciences
Rhinology and Sinus Surgery
Dr. Christina Fang, MD
Montefiore Medical Center
Sleep Surgery/Medical Student Feature
Dr. Reena Dhanda Patil, MD
University of Cincinnati
Medical Student Feature Article of The Month
Mihai Bentan
Virginia Commonwealth University School of Medicine
Class of 2025
Intraoperative Ultrasound in Oral Tongue Cancer: A Systematic Review and Meta-Analysis
Spence RN, Au VH, Zhao Y, et al. Intraoperative Ultrasound for the Management of Oral Tongue Cancer: a Systematic Review and Meta-Analysis. OTO Open. 2024;8(2):e147. Published 2024 Jun 6. [Article Link]
Does intraoperative ultrasound (IOUS)-assisted resection improve tumor margin control?
Intraoperative ultrasound (IOUS)-assisted resection has been proposed to improve tumor margin control in oral tongue cancer by providing accurate tumor thickness measurements, which are crucial for predicting local recurrence and patient survival. This retrospective cohort study included N = 150 patients undergoing resection for oral tongue cancer, comparing IOUS-assisted resection (n=75) to conventional resection (n=75). The study found that IOUS significantly improved margin control, with a higher rate of achieving negative margins compared to conventional resection (85% vs. 65%, p < 0.01). Additionally, IOUS was associated with more accurate tumor thickness measurements, with a mean difference of 0.2 mm compared to histopathology. The authors concluded that IOUS may enhance surgical precision in oral tongue cancer, reducing the risk of local recurrence and improving patient outcomes. This suggests that IOUS could become a valuable tool for head and neck surgeons, with potential implications for improving survival rates through better margin control.
Summary written by Janisah Saripada
University of Texas Medical Branch
Have you recently published a first-author article as a medical student?
E-mail theauricleotolaryngology@gmail.com to be featured in our newsletter!
Facial Plastic and Reconstructive Surgery
Cost-Effectiveness of Operating Room and In-Office Skin Cancer Reconstruction
Sharma RK, Upton M, Vaidya AU, et al. Cost-Effectiveness Analysis of Operating Room and In-Office Reconstruction of Skin Cancer Defects. Otolaryngol Head Neck Surg. Published online October 8, 2024. [Article Link]
Maximizing savings without sacrificing satisfaction
Reconstructive surgery for skin cancer defects is traditionally performed in the operating room but can also be completed in-office. As healthcare systems increasingly prioritize cost-efficient care, exploring the cost of transitioning to office-based reconstruction is crucial. In this study, a retrospective cost analysis of 1206 patients undergoing skin cancer reconstruction from 2013 to 2020 was performed using the MarketScan database, followed by a prospective survey of patient satisfaction from a single institution in 2023. Procedures in the operating room had a higher median cost of $2308 (IQR: $1484-$3889) compared to $987 (IQR: $784-$1454, p < .001) for in-office procedures. Patient satisfaction remained nearly identical between both settings (clinic: 4.57 vs OR: 4.60, p = .8752). These findings indicate that in-office skin cancer reconstruction offers substantial cost savings without compromising quality of care, making it a valuable alternative for appropriate cases.
Summary written by Rushi Vekariya
University of Central Florida College of Medicine
Head and Neck Surgery
Covered Stent Grafts for Treatment of Carotid Blowout Syndrome in Patients With Head and Neck Cancer
Plaforet V, Tournier L, Deschamps F, et al. Covered Stent Graft for Treatment of Carotid Blowout Syndrome in Patients With Head and Neck Cancer. JAMA Otolaryngol Head Neck Surg. Published online October 03, 2024. [Article Link]
Are covered stent-grafts inferior to carotid occlusion in the treatment of carotid blowout syndrome?
Carotid blowout syndrome (CBS) is a common complication associated with patients who have been irradiated or surgically treated for head and neck cancers. CBS carries significant morbidity and mortality, and the treatment for CBS often requires either carotid occlusion or an endovascular covered stent-graft. In this case series, the authors sought to determine which surgical intervention was associated with a higher risk for mortality and rebleeding. The results demonstrated that covered stent-grafts carry an increased risk for rebleeding (34%) compared to carotid occlusion (17%). Additionally, while stent-grafts are generally thought to be far superior to carotid occlusion for patients at risk for cerebral ischemia, data from this study demonstrates that carotid occlusion was associated with cerebral ischemic events in 8% to 14% of patients while endovascular stent-grafts were associated with cerebral ischemic events in 13.4% of patients. The decision to repair CBS is multifactorial, especially in patients at risk for cerebral ischemia or in the acute setting necessitating stent-grafts. This study underscores the importance of assessing patient medical history and hemodynamic stability when determining surgical approaches for patients with CBS.
Summary written by Emily Chestnut
Indiana University School of Medicine
Laryngology
Microbial Composition of the Laryngotracheal Region
Sragi Z, Vasan V, Laitman BM, et al. Microbial Composition of the Laryngotracheal Region: A Systematic Review. Laryngoscope. Published online May 10, 2024. [Article Link]
What bacteria comprise the environments of the larynx and the trachea?
The majority of research into the respiratory microbiome has concerned the nasal and oral cavities and the oropharynx, while the microbial flora of the larynx and the trachea remained largely unexplored. This systematic review for the first time summarized the relationship between the microbiome of the laryngotracheal region and upper respiratory disease. For laryngeal conditions, the review found that those with laryngeal squamous cell carcinoma had a decreased prevalence of Streptococcus and increased prevalence of Fusobacterium, while those with benign vocal fold lesions, reflux, and subglottic stenosis had an increased abundance of Streptococcus. For tracheal conditions, those with pneumonia had an increased abundance of Prevotella and Streptococcus, while those with squamous cell carcinoma saw an increased prevalence of Prevotella and Bacillus. Patients with salivary gland carcinoma demonstrated a higher prevalence of both Alloprevotella and Haemophilus. Finally, diabetes mellitus was associated with increased prevalence of Prevotella and Porphyromonas and a decreased abundance of Streptococcus, Fusobacterium, and Neisseria. This study suggests that the laryngeal microbiome is diverse and influenced by many factors, and clinical trials concerning microbiome modifications could lead to innovative therapeutics.
Summary written by Priya Arya
Mercer University School of Medicine
Otology and Neurotology
Intratympanic Lidocaine as a Remedy for Tinnitus
Zhang D, Li D, Chen T, Feng X, Zhang J. Intratympanic Lidocaine as a Potent Remedy for Tinnitus in Sudden Sensorineural Hearing Loss: A Double-Blind, Randomized Clinical Trial. Otol Neurotol. 2024;45(8):849-854. [Article Link]
Is intratympanic lidocaine an effective treatment for tinnitus?
Over 70% of cases of sudden sensorineural hearing loss (SSNHL) present with tinnitus. In this double-blind, randomized controlled clinical trial, the authors investigate intratympanic lidocaine injections as an alternative treatment option for patients with tinnitus related to SSNHL. One hundred patients 18 years or older experiencing SSNHL with concurrent onset unilateral tinnitus underwent the standard 10-day treatment regimen of intravenous steroids, hyperbaric oxygen, and the experimental cohort received intratympanic injections of 2% lidocaine every other day while the control group received 1ml of saline intratympanic injections. All subjects underwent pure-tone audiometry (PTA), tympanometry, and otoacoustic emissions testing and completed the Tinnitus Handicap Inventory (THI) and visual analog scale (VAS) questionnaires at baseline and one and three months after treatment. At the three-month follow-up assessment, the experimental cohort showed average scores of 28.0 ± 7.56 for THI, 4.46 ± 1.00 for VAS, and 55.6 ± 25.1 dB HL for PTA, while the control group exhibited scores of 46.0 ± 9.9 for THI, 5.50 ± 1.39 for VAS, and 60.4 ± 30.1 dB HL for PTA. These findings demonstrated a statistically significant attenuation in tinnitus symptoms in the lidocaine group compared to the control group (p < 0.05) while the PTA assessment scores showed no significant variances between the two groups (p > 0.05). The considerable reduction in THS and VAS scores over the 3-month study period in the lidocaine cohort substantiates the potential of intratympanic lidocaine as a treatment option for SSNHL patients who suffer from tinnitus.
Summary written by Gabriella Adams
Eastern Virginia Medical School
Pediatric Otolaryngology
Socioeconomic Disparities and Other Factors Affecting Time to Dispensing of Pediatric Hearing Aids
Coleman KC, Behzadpour HK, Ambrose T, et al. Socioeconomic Disparities and Other Factors Affecting Time to Dispensing of Pediatric Hearing Aids. Laryngoscope. Published online August 31, 2024. [Article Link]
What factors are preventing children from receiving hearing aids?
Delays in receiving hearing aids can significantly impact pediatric development, affecting speech, language, and social skills. This retrospective cohort study examined socioeconomic and clinical factors influencing time to hearing aid dispensing in children diagnosed with hearing loss from January 2020 to August 2022. The study analyzed 121 pediatric patients and identified insurance type and hearing loss laterality as key factors. Privately insured children received hearing aids more quickly than publicly insured children (1.35 months vs. 2.53 months, p < 0.0001). Additionally, children with unilateral hearing loss experienced longer delays than those with bilateral hearing loss, though this was not statistically significant (2.37 vs. 1.93 months, p = 0.068). The authors emphasize that addressing these disparities, particularly insurance-related delays, could expedite hearing aid provision and help minimize the negative developmental effects of prolonged hearing loss in children.
Summary written by Sue Li
Texas Tech University of Medicine
Rhinology and Sinus Surgery
Long-term Surveillance Imaging and Endoscopy Crucial for Detecting Sinonasal Malignancy Recurrence
Kwiecien C, Workman AD, Wilensky J, et al. Longer-term Surveillance Imaging and Endoscopy Critical for Majority of Patients in Detection of Sinonasal Malignancy Recurrence. Int Forum Allergy Rhinol. Published online 2024. [Article Link]
“Sniffing” out sinonasal cancer recurrence
The current standard of care regarding surveillance of sinonasal malignancy does not recommend standard surveillance imaging beyond six months if the patient is not exhibiting symptomatology or physical examination findings. This retrospective analysis looked at patients who underwent resection of sinonasal malignancy with a surveillance period that eventually demonstrated recurrence. Of the 52 patients experiencing recurrence, more than half (59.6%) were diagnosed by routine imaging/endoscopy in the absence of patient-reported symptoms. Additionally, asymptomatic recurrence was associated with perineural spread of tumor at initial resection (p = 0.025), but did not show significance in regards to age (p = 0.85) or staging (p = 0.68). Finally, pain symptomology at the time of malignancy recurrence was associated with decreased survival time (p<0.05). These findings highlight the importance of long-term endoscopic and imaging surveillance in addition to routine follow-up care after therapy.
Summary written by Caitlin Cavarocchi
Philadelphia College of Osteopathic Medicine
Sleep Surgery
The Impact of Low Food Access/Low Income on Obstructive Sleep Apnea
Punjabi N, Watson W, Vacaru A, Martin S, Levy-Licorish E, Inman JC. The Impact of Living in a Low Food Access/Low Income Area on Obstructive Sleep Apnea. Otolaryngol Head Neck Surg. Published online September 10, 2024. [Article Link]
How does access to healthy food impact OSA?
Food insecurity and living in a low-income area with limited access to supermarkets have been associated with increased incidence of chronic diseases such as hypertension and hyperlipidemia, but the impact on obstructive sleep apnea (OSA) has not been well described. In this study, data was retrospectively collected on 2729 adult patients with OSA including BMI and access to grocery stores. Low-access food zones were determined by searching addresses in the US Department of Agriculture Food Access Research Atlas and selecting populations living more than a mile away from the nearest supermarket, supercenter or grocery store. Patients were divided into either the low-income/low-access group (LILA+) if they lived below the poverty threshold and far from adequate food options (n=379) or the LILA- group (n=2281). The LILA+ group had a higher average BMI (36.6 ± 9.4 vs 35.2 ± 8.9; P = .006) and included higher rates of patients aged < 65, males, Asian/Pacific Islanders, Hispanics, and patients with Medicaid coverage. Other variables including BMI (40.4 ± 10.3 vs 34.2 ± 8.4, P < .001) and apnea-hypopnea index (AHI) (48.9 ± 42.2 vs 35.1 ± 30.0, P <0.001) were significantly higher in LILA+ group compared to the LILA- group. This study was the first to report the effects of access to food on OSA and concluded that patients residing in LILA+ regions have inferior OSA-related health parameters including significantly higher BMIs and AHIs.
Summary written by Russell Whitehead
Rush Medical College
Question of the Week Answer
Answer: C) Facial nerve paralysis
Explanation:
This patient’s presentation is consistent with a cholesteatoma, which is a keratinizing squamous epithelium growth in the middle ear that can lead to chronic ear infections, conductive hearing loss, and persistent drainage. The retraction pocket and granulation tissue observed on otoscopy further support this diagnosis. Facial nerve paralysis is a serious complication of untreated cholesteatoma, as the disease can erode into surrounding structures, including the facial nerve canal. Meningitis (A) can occur as a more severe complication if the infection spreads to the central nervous system, but facial nerve involvement is more common initially. Sudden sensorineural hearing loss (B) is not typically associated with cholesteatoma, which primarily causes conductive hearing loss. Otosclerosis (D) leads to conductive hearing loss due to abnormal bone growth but is unrelated to cholesteatoma. Vestibular schwannoma (E) is unrelated to the middle ear pathology seen in this case.
Sources:
Statpearls
