Clin. Otolaryngol. 2009, 34, 447-454. Objectives: We set out to determine the psychometric validation of a disease-specific health related quality of life instrument for use in chronic rhinosinusitis, the 22 item Sinonasal Outcome Test (SNOT-22), a modification of a pre-existing instrument, the SNOT-20. Design, setting and participants: The National Comparative Audit of Surgery for Nasal Polyposis and Chronic Rhinosinusitis was a prospective cohort study collecting data on 3128 adult patients undergoing sinonasal surgery in 87 NHS hospitals in England and Wales. Data were collected preoperatively and at 3 months after surgery, and analysed to determine validity of the SNOT-22. Test-retest reliability was assessed in a separate cohort of patients in a single centre. Main outcome measures: The SNOT-22, a derivative of the SNOT-20 was the main outcome measure. Patients were also asked to report whether they felt better, the same or worse following surgery. To evaluate the SNOT-22, the internal consistency, responsiveness, known group differences and validity were analysed. Results: Preoperative SNOT-22 scores were completed by 2803 patients. 3-month postoperative SNOT-22 scores were available for 2284 patients of all patients who completed a preoperative form (81.5% response rate). The Cronbach's alpha scores for the SNOT-22 were 0.91 indicating high internal consistency. The test-retest reliability coefficient was 0.93, indicating high reliability of repeated measures. The SNOT-22 was able to discriminate between patients known to suffer with chronic rhinosinusitis and a group of healthy controls (P < 0.0001, t = 85.3). It was also able to identify statistically significant differences in sub-groups of patients with chronic rhinosinusitis. There was a statistically significant (P < 0.0001, t = 39.94) decrease in patient reported SNOT-22 scores at 3 months. At 3 months the overall effect size in all patients was 0.81, which is considered large. We found the minimally important difference that is the smallest change in SNOT-22 score that can be detected by a patient, to be 8.9 points. Conclusions: We have found the SNOT-22 to be valid and easy to use. It can be used to facilitate routine clinical practice to highlight the impact of chronic rhinosinusitis on the patient's quality of life, and may also be used to measure the outcome of surgical intervention. The minimally important difference allows us to interpret scores in a clinical context, and may help to improve patient selection for surgery.
Clin. Otolaryngol. 2009, 34, 349-357 Objectives: To evaluate the efficacy and safety of a therapeutic bacteriophage preparation (Biophage-PA) targeting antibiotic-resistant Pseudomonas aeruginosa in chronic otitis. Design: Randomised, double-blind, placebo-controlled Phase I/II clinical trial approved by UK Medicines and Healthcare products Regulatory Agency (MHRA) and the Central Office for Research Ethics Committees (COREC) ethical review process. Setting: A single specialist university hospital. Participants: 24 patients with chronic otitis with a duration of several years (2-58). Each patient had, at the time of entry to the trial, an ear infection because of an antibiotic-resistant P. aeruginosa strain sensitive to one or more of the six phages present in Biophage-PA. Participants were randomised in two groups of 12 treated with either a single dose of Biophage-PA or placebo and followed up at 7, 21 and 42 days after treatment by the same otologist. Ears were thoroughly cleaned on each occasion and clinical and microbiological indicators measured. Main outcome measures: Physician assessed erythema/inflammation, ulceration/granulation/polyps, discharge quantity, discharge type and odour using a Visual Analogue Scale (VAS). Patients reported discomfort, itchiness, wetness and smell also using a VAS. Bacterial levels of P. aeruginosa and phage counts from swabs were measured initially and at follow-up. At each visit patients were asked about side effects using a structured form. Digital otoscopic images were obtained on days 0 and 42 for illustrative purposes only. Results: Relative to day 0, pooled patient- and physician-reported clinical indicators improved for the phage treated group relative to the placebo group. Variation from baseline levels was statistically significant for combined data from all clinic days only for the phage treated group. Variation from baseline levels was statistically significant for the majority of the patient assessed clinical indicators only for the phage treated group. P. aeruginosa counts were significantly lower only in the phage treated group. No treatment related adverse event was reported. Conclusion: The first controlled clinical trial of a therapeutic bacteriophage preparation showed efficacy and safety in chronic otitis because of chemo-resistant P. aeruginosa.
ObjectiveHearing loss affects over 1.23 billion people globally. It has been proposed that hearing impairment negatively impacts on cognition. Some studies have demonstrated a faster rate of decline in cognition, and increased risk of incident all-cause dementia. This finding is not ubiquitous. This study used meta-analysis to examine the evidence-base regarding the relationship between hearing and cognition. DesignA systematic review of the literature and meta-analyses of study findings were conducted. Published and grey literature was reviewed. Papers were included if they studied the relationship between hearing and cognition in adults with and without hearing impairment. Main outcome measuresMeta-analyses examined evidence for and against seven questions. Is cognition poorer in individuals with normal hearing compared to (i) untreated or (ii) treated hearing impairment, is cognition associated with degree of hearing impairment in (iii) untreated and/or (iv) treated hearing, is cognition (v) different in untreated compared to treated hearing impairment, (vii) does cognition improve after intervention, and (vii) how is hearing impairment differentially associated with cognitive ability across six domains of cognition? ResultsThe 33 included studies contributed 40 samples, with a total of 602 participants with untreated hearing impairment, 672 participants with treated hearing impairment, 176 healthy controls, and 4260 individuals with a range of hearing impairment with/without treatment. The results demonstrated that cognition is significantly poorer in (i) individuals with untreated hearing and remains poorer in (ii) treated hearing impairment compared to normal hearers. The degree of cognitive deficit is significantly associated with the degree of hearing impairment in both (iii) untreated and (iv) treated hearing impairment. Furthermore, (v) hearing intervention significantly improves cognition. Finally, (vii) hearing impairment impacted on all domains of cognition. ConclusionsThis meta-analysis suggests that hearing impairment is associated with cognitive problems. However, due to diversity within studies, small sample sizes, the failure to control for premorbid and other health factors, this conclusion may be premature.
Background: Eustachian tube dysfunction is regarded as a 'black box' term, reflecting a spectrum of dysfunction. The key to its diagnosis and management is in identifying the aetiology and exact pathophysiology of the dysfunction. Design: We present our retrospective 5-year results for the technique of transnasal endoscopic balloon dilatation of the cartilaginous part of the Eustachian tube, balloon Eustachian tuboplasty (BET). The indication for treatment is chronic obstructive Eustachian tube dysfunction. Main outcome measures: Preoperatively, the Eustachian tube score (ETS) was obtained by a clinico-objective assessment involving tubomanometry (TMM) and reported patient symptom. The measurements were repeated 1, 2, 3, 4 and 5 years postoperatively. Setting: Tertiary referral centre. Participants: A total of 622 patients (1076 ears) were treated with BET. Results: One year after treatment, the Eustachian tube score improved from 3.13 (+/- 2.47 SD) to 5.75 (+/- 2.76 SD). The Eustachian tube score improved significantly in 73% of ears. The average Eustachian tube score 2 years after treatment improved from 2.65 (+/- 2.89 SD) to 6.26 (+/- 3.07 SD). In 82% of patients, the Eustachian tube score improved significantly at 5 years. The subjective satisfaction of the patients was approximately 80%. Conclusions: Our long-term results suggest that BET is a safe and feasible treatment for chronic obstructive Eustachian tube dysfunction with a success rate of more than 70%. This study has important implications for other Eustachian tube-related clinical entities, such as glue ear management (adults and children), continued grommet insertion and tympanomastoid surgery outcomes.
ObjectivesTo evaluate video-head-impulse test (vHIT) results in normal subjects, to determine the normative values of vHIT for the vestibulo-ocular reflex (VOR) and to characterise the catch-up saccades (CSs). DesignProspective cohort study. SettingTertiary care academic referral centre. ParticipantsFifty healthy subjects with no history of vestibular impairment, ten each in their 20's, 30's, 40's, 50's and 60's, underwent vHITs in the lateral semicircular canal plane. Main outcome measuresvHIT gains and the incidence and amplitudes of covert and overt CSs. ResultsThe mean vHIT gain was 1.02 0.07, and the mean gain asymmetry was 2.39 +/- 1.96%, with no significant differences among age groups. CSs were observed during 22.6% of the trials and in 49% of the ears. The incidence of CSs was not associated with age. The mean velocity of CSs was 55.5 +/- 16.9 degrees/s, and its mean interaural difference was 11.8 +/- 10.7 degrees/s. ConclusionsvHIT gains were consistently equal to 1.0 in all age groups (20's to 60's), suggesting that abnormal criteria for vHIT gain (e.g. 0.8) and gain asymmetry (e.g. 8%) can be used, regardless of age. CSs were observed in about half of normal ears, suggesting that VOR is a hypometric system. The amplitudes and interaural difference of CSs were also similar in all age groups, suggesting that abnormal criteria for CS amplitude (e.g. 100 degrees/s) and interaural difference (e.g. 40 degrees/s) can be used, regardless of age.
ObjectiveTo assess the usefulness of voice quality measurements as a treatment outcome in patients with laryngopharyngeal reflux (LPR)-related symptoms. DesignProspective uncontrolled multi-centre study. Material and methodsA total of 80 clinically diagnosed LPR patients with a reflux finding score (RFS)>7 and a reflux symptom index (RSI)>13 were treated with pantoprazole and diet recommendations during 3 or 6months, according to their evolution. RSI; RFS; blinded Grade, Roughness, Breathiness, Asthenia, Strain and Instability (GRBASI) and aerodynamic and acoustic measurements were evaluated at baseline, 3months (n=80), and 6months (n=41) post-treatment. We conducted a correlation analysis between the adherence to the diet, and the evolution of both signs and symptoms and between videolaryngostroboscopic signs and acoustic measurements. ResultsReflux symptom index, RFS, perceptual voice quality evaluations (dysphonia, roughness, strain and instability), and aerodynamic and acoustic measurements (ie, percent jitter and percent shimmer) were significantly improved at 3months post-treatment but not at 6months. Percent jitter was the most useful outcome for evaluating the clinical evolution of patients throughout the treatment course. A significant relationship between globus sensation and posterior commissure hypertrophy was documented; both seemed to significantly improve from 3 to 6months. The correlation analysis revealed correlations between adherence to diet recommendations and the improvement of symptoms and between posterior commissure granulation severity and acoustic measurement impairments. ConclusionVoice quality improved in a manner similar to both signs and symptoms throughout a 6-month empirical treatment with better improvement the 3 first months. Voice quality assessments can be used as indicators of treatment effectiveness in patients with LPR-related symptoms.
Objectives: To investigate the relationship between hearing loss and cardiovascular disease risk factors. Design: Cross-sectional study. Methods: Participants were recruited between May 2010 and December 2015 and answered a health and risk factor questionnaire. Physical and biochemical assessments were performed. Setting: A community-based population. Participants: A total of 5107 participants born within the years 1946-1964 enrolled in the Busselton Healthy Ageing Study. Main outcome measures: Hearing was assessed behaviourally through the best ear pure-tone average (500, 1000, 2000, 4000 Hz), low-frequency average (250, 500, 1000 Hz) and high-frequency average (4000, 8000 Hz). Self-reported hearing loss, tinnitus and hyperacusis were assessed via questionnaire. Cardiovascular risk factors were assessed via a patient-completed questionnaire and objective measurements including blood pressure, body mass index, waist circumference, lipid profile and glycated haemoglobin. Results: Of the participants, 54% were female, with the mean age of 58 years (range 45-69 years). Age, sex and family history of hearing loss were consistently strong determinants of hearing loss outcomes. After adjusting for these, obesity, current smoking, peripheral arterial disease and history of cardiovascular disease were significantly associated with pure-tone, low-frequency and high-frequency hearing loss. In addition, high blood pressure, triglyceride and glycated haemoglobin were significantly associated with low-frequency hearing loss. There was a graded association between hearing loss and Framingham Risk Score for cardiovascular risk (P< 0.001). Conclusions: Established cardiovascular disease and individual and combined cardiovascular disease risk factors were found to be associated with hearing loss. Future research should prospectively investigate whether targeting cardiovascular disease can prevent hearing loss.
ObjectivesTo describe the development of an enhanced recovery after surgery (ERAS) protocol for people undergoing surgery for head and neck cancer. DesignService improvement project. ParticipantsHead and neck oncology patients. MethodsThe programme was developed in a series of structured meetings over a 6-month period. Stakeholders included oral and maxillofacial surgeons, otolaryngologists, anaesthetists, dieticians, physiotherapists, speech and language therapists (SALT) and nursing staff. Based on evidence within current literature and a consensus among the group, an ERAS programme for head and neck surgery patients was formulated. A 12-month study of compliance with the ERAS programme was undertaken from February 2014 to January 2015. ResultsThe process has resulted in the realisation of a head and neck ERAS programme. Key elements include a patient diary, nutritional optimisation, avoiding tracheostomy when possible, goal-directed fluid therapy intra-operatively and a specific head and neck postoperative pain management protocol. Overall compliance was high. Important areas showed lower levels of compliance - only 55% of people were given an explanation of the ERAS programme preoperatively, 75% took preoperative carbohydrate drinks, 10% had individualised goal-directed fluid therapy, and 7% were mobilised in the first 24h after surgery. The mean length of hospital stay was 14.55days (sd 7.48). ConclusionsThe ERAS programme developed is now embedded in the care pathway for people undergoing head and neck cancer surgery in our unit. The mean length of hospital stay has reduced since the introduction of the programme.
ObjectivesTo define clinical subgroups by cluster analysis in patients with unilateral Meniere disease (MD) and to compare them with the clinical subgroups found in bilateral MD. DesignA cross-sectional study with a two-step cluster analysis. SettingsA tertiary referral multicenter study. ParticipantsNine hundred and eighty-eight adult patients with unilateral MD. Main outcome measures: best predictors to define clinical subgroups with potential different aetiologies. ResultsWe established five clusters in unilateral MD. Group 1 is the most frequently found, includes 53% of patients, and it is defined as the sporadic, classic MD without migraine and without autoimmune disorder (AD). Group 2 is found in 8% of patients, and it is defined by hearing loss, which antedates the vertigo episodes by months or years (delayed MD), without migraine or AD in most of cases. Group 3 involves 13% of patients, and it is considered familial MD, while group 4, which includes 15% of patients, is linked to the presence of migraine in all cases. Group 5 is found in 11% of patients and is defined by a comorbid AD. We found significant differences in the distribution of AD in clusters 3, 4 and 5 between patients with uni- and bilateral MD. ConclusionsCluster analysis defines clinical subgroups in MD, and it extends the phenotype beyond audiovestibular symptoms. This classification will help to improve the phenotyping in MD and facilitate the selection of patients for randomised clinical trials.
ObjectivesTo analyse post-tonsillectomy haemorrhage (PTH) rates related to technique for dissection and haemostasis. Study DesignRegister study from the National Tonsil Surgery Register in Sweden (NTSRS). MethodsAll patients, subjected to tonsillectomy (TE) without adenoidectomy from 1 March 2009 to 26 April 2013, were included in the study. The surgeon reports data about technique and early PTH, while late PTH is reported by the patient in a questionnaire 30days after surgery. Results15734 patients with complete data concerning technique for dissection and for haemostasis were identified in the NTSRS. Techniques used were cold steel dissection with uni- or bipolar diathermy haemostasis (65.3%), diathermy scissors (15.7%), coblation (9.1%), cold steel dissection with cold haemostasis (7.4%) and ultrascision (2.5%). Early and late PTH were reported in 3.2% and 9.4% of the cases, respectively, and return to theatre (RTT) in 2.7%. The rates for PTH and RTT related to technique were analysed. Compared with cold dissection+ cold haemostasis, late PTH rate was 2.8 times higher after cold dissection + hot haemostasis, 3.2 times higher after coblation, 4.3 times higher after diathermy scissors and 5.6 times higher after ultrascision. The risk for RTT was higher for all hot techniques except for coblation, while ultrascision resulted in a lower risk for early PTH. ConclusionsAll hot techniques resulted in a higher risk for late PTH compared with cold steel dissection +cold haemostasis. The risk for RTT was higher for all hot techniques except for coblation, while ultrascision resulted in a lower risk for early PTH. An early PTH was associated with an increased risk for late PTH.
ObjectivesThe diagnosis of cancer of unknown primary (CUP) in head and neck occurs when the treating clinicians have utilised all available diagnostic tests and failed to identify the origin of the disease. There is no agreed consensus on which diagnostic investigations to use, or the order in which to use them in, although broad recommendations exist. Small tumours arising in the tongue base can be below the limits of resolution of conventional diagnostic techniques. Given the difficulty in targeting the tongue base, current practice involves blind random biopsies, which leads to a variable detection rate. Robotically assisted surgical removal of the tongue base, tongue base mucosectomy (TBM) has been shown to improve diagnostic yield. This study reports the diagnostic hit rate for tongue base primaries using this technique. DesignRetrospective case review. SettingUK Head and Neck Centres. ParticipantsPatients presenting as an unknown primary, investigated with clinical examination, PET-CT and palatine tonsillectomy. Main Outcome MeasuresThe detection of a primary site of head and neck cancer in the otherwise unknown primary tumour. ResultsThe primary tumour site was identified in the tongue base in 53% (n=17) of patients. In 15 patients the tumour was in the ipsliateral tongue base (88%) while in two cases (12%) the tumour was located in contra lateral tongue base. ConclusionsTrans-oral robotic assisted TBM raises the possibility of identifying over 50% of tumours that would otherwise be classified as CUP. Identifying these in the contralateral tongue base has implications for treatment planning and outcome.
OBJECTIVES: To describe the health-related quality of life of patients visiting a tertiary referral centre for facial palsy, and to analyse factors associated with health-related quality of life, using the FaCE Scale instrument. DESIGN: Retrospective cohort study. SETTING: The Facial Nerve Center at the Massachusetts Eye and Ear Infirmary, a tertiary referral centre. PARTICIPANTS: Patients with a peripheral facial palsy visiting the centre for an initial consultation between August 2007 and June 2012. MAIN OUTCOME MEASURES: The total FaCE score and the FaCE social function subdomain. Multiple regression models were developed to identify factors associated with the total FaCE score and FaCE social function score. RESULTS: A total of 794 patients with a mean age of 47.0 +/- 16.0 years were analysed in this study, of which 59.9% were female. The mean House-Brackmann, Sunnybrook, total FaCE and FaCE social function scores were 3.6 +/- 1.5, 48.2 +/- 21.2, 47.3 +/- 19.3 and 55.5 +/- 19.2, respectively. Increasing age (r = -0.229, P < 0.001) was associated with a lower total FaCE score. Female gender (r = -4.422, P = 0.033) and increased duration of palsy (r = -0.018, P = 0.041) were associated with lower FaCE social function scores. CONCLUSIONS: While counselling patients on what to expect during the recovery process after facial paralysis is an important part of any clinical visit, FaCE score correlations suggest that female patients with chronic facial palsy and increased age constitute a patient category that may require additional time and attention to prevent or mitigate psychosocial dysfunction.
Background: Age-related hearing loss (ARHL) is highly prevalent in older adults, and more than two-thirds above age of 70 years suffer from ARHL. Recent studies have established a link between ARHL and cognitive impairment; however, most of the studies have used verbally loaded cognitive measures to investigate the association between ARHL and cognition. It is possible that due to hearing impairment, the elderly may experience difficulty in following verbal instructions or completing tasks that heavily rely on hearing during cognitive assessments. This may result in overestimation of cognitive impairment in such individuals. This baseline cross-sectional study investigated the associations between untreated hearing loss and a number of cognitive functions using a battery of non-verbal cognitive tests. Further, association between hearing loss and psychological status of older adults was examined. Study design: Prospective case-controlled study. Methods: A total of 119 participants (54 males, M= 66.33 +/- 10.50 years; 65 females M= 61.51 +/- 11.46 years) were recruited. All participants completed a hearing assessment, a computerised test battery of non-verbal cognitive functions and the depression, anxiety and stress scale. Results: Hierarchical multiple regression analysis results revealed that hearing thresholds significantly associated with the working memory (P< 0.05), paired associative learning scores (P< 0.05), depression (P< 0.001), and anxiety (P< 0.001) and stress (P< 0.001) scores. Analysis of covariance results revealed that participants with moderately-severe hearing loss performed significantly poorer in paired associative learning and working memory tasks and psychological function tests compared to those with normal hearing. Conclusion: Results of the current study suggest a significant relationship between ARHL and both cognition and psychological status. Our results also have some implications for using non-verbal cognitive tests to evaluate cognitive functions in post-lingually hearing impaired ageing adults, at least for those with more than moderately- severe levels of hearing loss.
Objectives The primary objective of this study was to determine how computational fluid dynamics (CFD) could be correlated to clinical evaluation of nasal airway obstruction (NAO) in a population of patients with symptomatic septal deviation (SD). The secondary objective was to determine whether CFD could define which side was the more obstructed. Design This was an observational study. Settings Few publications have attempted to correlate CFD with clinical evaluation of NAO. This correlation would permit validation and improved interpretation. This study was performed in a university research laboratory specialised in fluid mechanics. Participants We included patients referred for septal surgery at our centre. Age range was 19-58 years. Preoperative CT scans were performed. All patients with non-structural causes of NAO such as rhinitis, sinusitis or tumoral/autoimmune processes (ie, not due to anatomic obstruction) were excluded. Main outcome measurement For each nasal fossa, we compared CFD data (total pressure, heat flux, wall shear stress, temperatures, velocity and nasal resistances) with both patient perception scores and rhinomanometry using the Spearman correlation test (r(s)). Perception scores were graded from 0/4 to 4/4 on each side, based on the patient interview. We also compared CFD-derived nasal resistances with rhinomanometry-derived nasal resistances. Results Twenty-two patients complaining of NAO with SD were analysed, and 44 analyses were performed comparing each side with its CFD data. Regarding correlations with patient perception scores, the best values we found were heat flux measures (r(s) = 0.86). Both rhinomanometry and CFD-calculated nasal resistances had strong correlations with subjective perception scores (r(s) = 0.75, P r(s) = 0.6, P < 0.001, respectively). We found a statistically significant difference between RMM-NR and CFD-NR (P = 0.003). Heat flux analysis allowed us to distinguish the more obstructed side (MOS) and the less obstructed side (LOS) in 100% of patients. Conclusion This study aimed to enhance our ability to interpret CFD-calculated data in the nasal airway. It highlights and confirms that heat flux measures are very closely correlated to patient perception in cases of SD. It also helps to distinguish the more obstructed side from the less obstructed side and could contribute to further CFD studies.
Background It is generally accepted that intratympanic injection provides an effective approach to manage severe vertigo in Meniere's disease. Although there are several medications available, that which is the most effective is still subject to debate. Objective To assess the effectiveness and safety of the different medications used in the treatment of Meniere's disease by intratympanic injection using a network meta-analysis. Methods PubMed, EMBASE, CINAHL and CENTRAL were searched. Only randomised controlled trials that compared the effectiveness of medications used for intratympanic injection to treat Meniere's disease with each other or a placebo were included. The primary outcome assessed was the effectiveness of medication in the management of vertigo symptoms. The effectiveness was expressed in terms of risk ratio (RR) with a 95% credible interval (CrI) for individual studies analysed. Network meta-analyses were performed by Stata version 15.0 using the network package. Results Nine studies involving 314 patients treated with five different medications were included in the present analysis. A number of injections given varied from 1 to 10 and the follow-up time from 3 to 28 months. When compared to each other or to a placebo, Gentamicin was found to be the most efficacious medication, followed by Methylprednisolone, Latanoprost, Dexamethasone and Ganciclovir in order of effectiveness. However, no significant difference in efficacy was found between Gentamicin and Methylprednisolone when outcomes from studies with a follow-up time equal to or more than 24 months were analysed. It was not possible to conduct subgroup and sensitivity analysis because of the limited number of studies that were included. Conclusion All medications are more effective than a placebo in the treatment of Meniere's disease by intratympanic injection. According to the SUCRA, Gentamicin ranked the most effective, with Gentamicin and Methylprednisolone equally effective in the long-term effect. When the potential risk of hearing loss induced by Gentamicin is taken into consideration, Methylprednisolone may be the best choice for the treatment of Meniere's disease by intratympanic injection.
To summarize current knowledge about the prevalence, etiology and management of recalcitrant laryngopharyngeal reflux (LPR) patients - those who do not respond to anti-reflux medical treatment. A literature search was conducted following the PRISMA guidelines to identify studies that reported success of anti-reflux medical treatment with emphasis on studies that attempted to be rigorous in defining a population of LPR patients and which subsequently explored the characteristics of non-responder patients (i.e. etiology of resistance; differential diagnoses; management and treatment). Three investigators screened publications for eligibility from PubMED, Cochrane Library and Scopus and excluded studies based on predetermined criteria. Design, diagnostic method, exclusion criteria, treatment characteristics, follow-up and quality of outcome assessment were evaluated. Of the 139 articles screened, 45 met the inclusion criteria. The definition of non-responder patients varied substantially from one study to another and often did not include laryngopharyngeal signs. The reported success rate of conventional therapeutic trials ranged from 17 to 87% and depended on diagnostic criteria, treatment scheme, definition of treatment failure, and treatment outcomes that varied substantially between studies. The management of non-responders differed between studies with a few differential diagnoses reported. No study considered the profile of reflux (acidic, weakly acid, nonacid, or mixed) or addressed personalized treatment with the addition of alginate or magaldrate, low acid diet, or other interventions that have emerging evidence of efficacy. To date, there is no standardized management of LPR patients who do not respond to traditional treatment approached. A diagnostic and therapeutic algorithm is proposed to improve the management of these patients. Future studies will be necessary to confirm the efficacy of this algorithm through large cohort studies of non-responder LPR patients. This article is protected by copyright. All rights reserved.
The objective of this study was to analyse MRI with morphological (T1, T2) and diffusion sequences (DWI, b1000) in patients presenting non-aggressive patterns of sinus opacity and operated on by functional endoscopic sinus surgery (FESS). A retrospective study. Diffusion imaging in paranasal sinus pathology remains little known. To date, no imaging system is capable of determining the purulent content of a non-enhanced sinus filling. We included consecutive patients having undergone FESS in whom MRI of the paranasal sinuses was performed. Subjects were allocated to Case (pus) or Control (no pus) groups depending on sinus content found intraoperatively. FESS was performed for bacterial acute rhinosinusitis, acute exacerbations of chronic rhinosinusitis, non-purulent sinusitis, naso-sinusal polyposis, antrochoanal polyp, isolated polyp, angiomatous polyp and eosinophilic fungal sinusitis. Tumours, mucoceles and fungus balls were excluded. We analysed T1, T2, b1000 and MRI sequences and ADC map. On univariate analysis, intermediate signal in T2 and high signal in b1000 were associated with Cases (P brain was significantly associated with the case group. MRI with b1000_SI 1.450 × 10 mm /sec was significantly associated with the control group. Diffusion MRI offers extremely promising results regarding content characterisation of infectious sinus diseases.