Editorial: Blending Medical and Surgical Therapies to Optimize Patient Outcomes in Chronic Rhinosinusitis and Allergic Rhinitis
The July issue of American Journal of Rhinology and Allergy features an array of fascinating articles exploring cutting edge therapies in the management of chronic rhinosinusitis (CRS) as well as covering several new studies examining the pathophysiology of allergic rhinitis (AR) While endoscopic sinus surgery is nearing its third decade in clinical use, novel techniques, instrumentation, and postoperative management strategies continue to be actively developed. In this issue Sanjuan de Moreta et al1 describe their technique of "centripetal endoscopic sinus surgery(CESS)" based on early identification of the medial orbital wall and anterior skull base as constant landmarks. Using this technique over a five year period they reported a 3.5% revision rate among 114 patients suggesting that this technique is a reasonable method, particularly in patients with distorted anatomy. A study by Bikhazi et al2 continues to advance our understanding of the role of clinic based balloon sinuplasty. This group performed a multi center, prospective, randomized trial to evaluate 1 year outcomes following stand alone office balloon dilation versus functional endoscopic sinus surgery (FESS) in medically refractory patients with maxillary sinusitis. Fifty patients underwent balloon dilation as compared to 42 who underwent FESS. Both groups demonstrated significant improvement in both SNOT 20 scores and overall work productivity. Both groups also demonstrated durable ostial patency suggesting that in office stand alone balloon sinus dilatation is an effective technique in this carefully selected patient population. Eren et al3 reported on the success of septoplasty as measured by symptoms, acoustic rhinometry, and peak nasal inspiratory flow based on previously reported deviation types. They found that deviation types 2,4, and 6 benefitted most from surgery suggesting that patients may be counseled on expected outcomes based on their preoperative deviation morphology. Techniques to optimize postFESS wound healing are also explored in this issue. Yu et al4 compared the local effects of aerosolized fibrin sealant to merocel packing. They demonstrated a significant reduction in granulation and crusting in the fibrin group as well as improved patient satisfaction and willingness to reuse the material. This study suggests that aerosolized fibrin sealant may be a viable alternative to merocel sponges in the post FESS setting. As our outcomes and techniques in FESS continue to advance, our field must also continue to strive to improve how we teach the next generation of otolaryngologists. This month features two studies addressing ways to help train residents in the surgical management of rhinologic disorders. Varshney et al5 describe an advanced FESS simulator developed in conjunction with the National Research Council of Canada. This is the first such device capable of simulating newer instrumentation such endonasal wash and complex anatomic deformities. Obeid et al6 report on a new Objective Structured Assessment of Technical Skills (OSAT) based form for the quantification and documentation of resident skill in septoplasty. This tool was tested on 21 otolaryngology residents over a 2 year period and demonstrated good validity, reliability, and feasibility for assessing competency in septoplasty surgery. Finally, Lawson et al7 reported on a new classification system for sinonasal sarcoidosis. They categorize patients into atrophic, hypertrophic, destructive, and nasal enlargement subgroups, each of which may respond differently to treatment. This new system may help both trainees and experienced practitioners recognize and treat patients with sinonasal manifestations of sarcoid disease. As our understanding of CRS continues to evolve, it is ever more clear that concomitant medical management is a critical adjunct to surgical technique in maintaining durable results. Chaudhry et al8 performed a retrospective study on the utility of triamcinolone acetate in carboxymethylcellulose for acute exacerbations in patients with chronic sinusitis with nasal polyps. This study reported on 371 patients treated over a 5 year period and found an improvement in SNOT 22 scores and a decrease in prednisone use. These findings suggest that this topical treatment may be a good alternative to oral steroid use for exacerbations among patients with nasal polyps. Casale et al9 examined hyaluronic acid as another potential topical agent for use in CRS. They performed an open label, randomized study of the role of nebulized hyaluronic acid versus saline in the reduction in symptoms and prevention of exacerbations in patients with CRS. This study demonstrated an improved quality of life in the hyaluronic acid group along with reduced edema and secretions relative to the saline alone group. These findings suggest that intermittent treatment with hyaluronic acid may be of benefit in patients with CRS. Wentzel et al10 explored the role of environmental exposures in CRS. This group studied the prevalence of passive smoke exposure in CRS by quantifying hair nicotine levels and stratifying patients into passive smoke exposed and smoke naive groups. The study found that the prevalence of smoke exposure was equivalent between CRS and control groups and there were no temporal changes in annual passive smoke exposure prevalence despite the regional implementation of smoking bans. This study further demonstrated that objective measures of exposure did not agree with previously reported subjective measurements. This study suggests that the role of smoke exposure in CRS exacerbations should be further studied using objective measures. Tsou et al11 reported on an important epidemiologic study attempting to ascertain whether CRS or nasal polyps are associated with an increased risk of nasopharyngeal cancer in Taiwan. Among this population, CRS patients were found to have a 3.55 fold increased risk of developing nasopharyngeal carcinoma as compared to the control population suggesting that these patients should be screened during their routine treatment for sinusitis. This issue also explores novel mechanisms and treatment options in the management of allergic rhinitis with several high quality articles. Choi et al12 explored the role of the microbiome in AR and demonstrated that patients with seasonal allergic rhinitis had greater bacterial diversity in season than their non allergic counterparts providing a possible link between allergic rhinitis and acute bacterial rhinosinusitis. Meng et al13 examined the association between both serum and nasal secretion levels of immunoglobulin free light chain (IgFLC) and rhinitis. They found that FLC positive cells were significantly increased in both allergic and non allergic rhinitis mucosa and that levels correlated with other inflammatory mediators. These findings raise the possibility that IgFLC may have a role in promoting mucosal inflammation in patients with both allergic and non allergic rhinitis. Finally, Johns and Laidlaw14 studied patients with aspirin exacerBenjamin Bleier, M.D.
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