Are All Cases of Sinusitis the Same?

Ongoing and emerging research is providing a fuller picture of chronic rhinosinusitis (CRS) as a spectrum of diseases that goes beyond the current clinical phenotyping, based largely on the presence or absence of nasal polyps, to a deeper recognition of distinct subtypes of the disease based on pathogenic mechanisms.

It is hoped that research into these subtypes will lead to the ability to use them as biomarkers to better predict how best to treat patients with CRS, particularly given the rapid development and availability of biologic agents aimed at targeting specific pathologic mechanisms of disease.

The need for improved tailored treatments for people with CRS is highlighted by the sheer number of people with sinusitis symptoms, a limited ability to adequately treat these patients based on symptoms, and the current reliance on the presence or absence of polyps. “The epidemiology of CRS is still a work in progress, but studies suggest that a huge number of people, probably 39 million in this country, have the symptoms of chronic rhinosinusitis,” said Robert Kern, MD, chair of the department of otolaryngology–head and neck surgery at Northwestern Feinberg School of Medicine in Chicago, “Of those, I would estimate that perhaps 26 million or so really have sinusitis, confirmed by computed tomography, of which only approximately six million have polyps.”

Although targeting patients with polyps for treatment with intranasal and oral corticosteroids is the standard treatment approach, its impact on outcomes is less than satisfactory, he said. “Phenotyping or clinical evaluation alone has made only a limited impact on clinical care, or even the ability to tell a patient if they will do well or not on a given treatment,” he said.

To improve clinical outcomes, researchers like Dr. Kern are looking beyond clinical patterns of sinusitis into the patterns of tissue inflammation as a guide to better improve their ability to identify the patient subsets who will benefit from specific treatments. Called endotyping, the research looks at the underlying pathogenic mechanisms of disease, an approach that is similar to research that has already been conducted in the study of asthma and other atopic diseases.

For clinicians, this research, combined with ongoing studies into more advanced phenotyping based on attributes such as age and geography, highlights the need to look at CRS not as a singular disease, but as one with distinct clinical presentations and disparate—probably related—pathogenic mechanisms. “It is important to understand that all CRS patients are different,” said Justin H. Turner, MD, PhD, associate professor of otolaryngology–head and neck surgery at Vanderbilt University in Nashville. “CRS is a clinical syndrome, and patients may present very differently and have variable responses to medical and surgical interventions.”

Robert Kern, MDIn the future, we will be able to subdivide patient groups more precisely, and that will lead to rolling out precision, personalized medicine in which we can really predict from mucus or a blood sample how to treat patients. —Robert Kern, MD

Clinical Patterns and Subtypes

Although the presence or absence of nasal polyps is the cornerstone on which the current treatment of CRS is based, additional information on the clinical patterns of CRS is emerging that provides more direction for clinicians. These data point toward clinical indicators such as age, geography, ethnicity, and others associated with different underlying pathogenic mechanisms of CRS and, therefore, support the use of endotyping.

One area of research suggests the importance of age in distinguishing the type of inflammation and its potential impact on treatment outcomes. Dr. Turner and his colleagues recently published a study in which they found that older people with CRS had elevated tissue and mucus levels of pro-inflammatory cytokines associated with innate immune system dysfunction, were more likely to harbor colonizing bacteria in the sinonasal tract, and had more neutrophilic inflammation regardless of polyp status or other clinical variables when compared with younger patients (J Allergy Clin Immunol. 2019;143:990–1002). “Older CRS patients may appear similar to younger patients on physical exam but differ in many other ways,” said Dr. Turner. “Given the unique inflammatory signature that we have identified in older patients, we feel that it is essential that age be taken into account when planning treatment approaches.”

Specifically, when examining tissue and mucus specimens of 147 patients ranging in age from 18 to 78 years who underwent sinus surgery for CRS, the investigators found that the inflammatory signature of a subgroup of patients older than age 60 was very different from that found in patients younger than 60. Whereas the inflammatory signature in the younger patients was characterized by a group of cytokines (Th2-associated) found in most CRS in North America, these cytokines were not significantly elevated in older patients. Rather, the inflammatory signature in the older patients was associated with a neutrophilic proinflammatory response characterized by an elevation in cytokines linked to the body’s innate immune function and acute and chronic inflammatory response. “You don’t see an elevation in those cytokines until around age 60, and then from that age on, there’s a progressive increase in the levels of those cytokines seen in the mucus and tissue of those patients,” said Dr. Turner.

One important implication of this finding is that current treatment approaches for CRS may be less effective in older patients. “Neutrophilic inflammation is typically less responsive to topical and systematic corticosteroids,” said Dr. Turner. “This would suggest that great care should be taken when prescribing repeated courses of oral steroids in older patients, and strongly suggests the need for alternative therapies to more effectively target this vulnerable population.”

Another area of research shows that people with CRS living in Asian countries are likely to have more neutrophilic inflammation than people living in Europe/North American countries. For example, a 2017 study found that most people with CRS in Europe/North America (80%) have nasal polyps characterized by increases in eosinophilic cytokines (type 2 inflammation), compared to 20% in China and 60% in Korea or Thailand (J Allergy Clin Immunol. 2017;140:1230–1239).

According to Amber Luong, MD, PhD, associate professor in the department of otorhinolaryngology–head and neck surgery at McGovern Medical School of The University of Texas Health Science Center at Houston, the differences in the types of inflammation found in nasal polyps in these geographical populations highlights the fact that while people with CRS can look clinically similar (i.e., have the presence of nasal polyps), they are very different molecularly.

Justin H. Turner, MDAll CRS patients are different. CRS is a clinical syndrome and patients may present very differently and have variable responses to medical and surgical interventions. —Justin H. Turner, MD

She emphasized, however, that this is not an ethnic difference per se, adding that nasal polyps in second generation Asians with CRS living in Northern America or Europe are starting to look molecularly similar to nasal polyps in the populations of these countries. “This observation suggests that environmental exposure plays a critical role in driving the type of immune response contributing to rhinosinusitis,” she said. On the other hand, she cited a 2018 study that found that variations in cut-off levels of eosinophil numbers used to diagnose eosinophilic versus neutrophilic chronic rhinosinusitis may contribute to some of the differences in the percent of eosinophilic versus neutrophilic CRS between eastern and western countries (Curr Allergy Asthma Rep. 2018;18:46). Nonetheless, she added, the 2017 study highlights the fact that not all polyps are the same at a molecular level.

To that end, she said the research is pointing toward the future. “Maybe down the road you can take a biopsy sample that helps us to endotype our patients with chronic sinusitis,” she said.

For Noam A. Cohen, MD, PhD, director of rhinology research in the department of otorhinolaryngology–head and neck surgery at Perelman School of Medicine at the University of Pennsylvania in Philadelphia, another important component of what he sees as a multifactorial approach to explaining CRS is looking at taste receptors and the role they play in the development of the disease.

In studies published in 2012 and 2014, he and his colleagues showed that people with sensitive bitter taste receptors are less likely to develop a subtype of CRS based on the genetically determined function of these taste receptors (J Clin Invest. 2012;122:4145–4159; J Clin Invest. 2014;124:1393–1405). The research showed that one bitter taste receptor detects the molecule secreted by gram-negative bacteria that subsequently stimulate an immediate defense (nitric oxide production) in the cells lining the sinuses, which kills and clears out bacteria that play a common role in sinusitis. “What the receptor triggers is like a switch turned on in response to the bacteria, which not only kills the bacteria but sweeps the dead bugs away,” said Dr. Cohen.

Where this gets interesting, he said, is that there are a lot of genetic differences in the ability of people to taste bitter molecules. “Over the past five to six years, we’ve been able to show that patients in whom this bitter taste receptor doesn’t work are at much higher risk for developing gram-negative sinusitis,” he said.

With this finding, Dr. Cohen and his colleagues then looked at whether you could use the presence or absence of functioning bitter taste receptors to predict surgical outcomes, and they found that a subset of CRS patients without the functioning receptor were at higher risk for sub-optimal surgical outcomes.

Currently, Dr. Cohen and his colleagues are gearing up to launch a clinical trial to see whether it is possible for patients with CRS to forego conventional antibiotics after activation of their multiple bitter taste receptors and natural defense mechanism against the bacteria that cause rhinosinusitis.

Patterns of Inflammation

The potential to identify specific molecular biomarkers of CRS to individualize treatment is being advanced through research on CRS endotyping, through which investigators are looking at the patterns of inflammation in the tissue of nasal polyps in people with CRS. “We still rely on phenotypes in the clinic,” said Dr. Kern, “but we can gaze at the future in terms of endotyping.”

A recent study by Dr. Kern and colleagues that looked at the presence of subsets of innate lymphoid cells (ILCs) found that the subset ILC2 may play an important role in the development of type 2 inflammation found in patients with CRS and nasal polyps (Immun Inflammation Dis. 2017;5:233–243). In the study, the investigators used multiple techniques to look at the presence of subsets of ILCs in patients with CRS, both with and without nasal polyps. ILCs, along with T-helper lymphocytes, produce high levels of cytokines that are present in distinct patterns in the tissue. These patterns will likely define the clinically relevant endotypes, each of which will respond differently to current treatment options. Type 2 inflammation, defined by the presence of elevated type 2 cytokines (IL-4, 5 and 13), is present in the vast majority of patients with CRS with nasal polyps. This Type 2 endotype—or, more likely, a group of related type 2 endotypes—has been particularly difficult to treat, with a high recurrence rate after both medical and surgical therapy. Type 1 and Type 3 inflammations are less common and likely more responsive to treatment. In CRS patients without polyps, the inflammation is more heterogeneous, but a large percentage still exhibit Type 2 inflammation.

Figure 1. Unique Inflammatory Signatures in Aged CRS Patients. Reprinted from J Allergy Clin Immunol. 2019;143:990–1002, Copyright 2019, with permission from Elsevier.

Figure 1. Unique Inflammatory Signatures in Aged CRS Patients.
Reprinted from J Allergy Clin Immunol. 2019;143:990–1002, Copyright 2019, with permission from Elsevier.

According to Dr. Kern, each pattern of inflammation will likely respond differently to various treatment options in ways that should be predictable. “We are still working this out,” he said, emphasizing that the research is only relevant if it has clinical application—that is, if it can shed light on the natural history of the disease, help predict who will respond to what treatment, and determine which patients will do well on a given treatment.

For Dr. Kern and others, this is the direction in which CRS treatments are heading. “In the future, we will be able to subdivide patient groups more precisely, and that will lead to rolling out precision, personalized medicine in which we can really predict from mucus or a blood sample how to treat patients,” he said.

Underscoring the need for further research is the emergence of biologic agents that can target specific mechanisms of disease, a treatment already used for patients with asthma. This advance is on the doorstep for patients with CRS. Dr. Kern pointed to results of a study recently presented at the American Academy of Allergy, Asthma and Immunology (AAAI) meeting in February 2019 that showed the safety and efficacy of the biologic agent dupilumab for nasal polyps (“Efficacy and safety of dupilumab in patients with chronic rhinosinusitis with nasal polyps: results from the randomized phase 3 SINUS-24 study”).

According to Dr. Kern, the biologic agent will hopefully gain approval from the Food and Drug Administration for treatment of nasal polyps sometime later this year, representing a major advance in the ability to manage patients with severe CRS with nasal polyps. 

Mary Beth Nierengarten is a freelance medical writer based in Minnesota.

ENT Today

Basic Science Departments Struggle Amid Financial, Staffing Challenges

Basic science departments serve three key missions: to conduct research, to teach graduate students in basic science fields, and to teach medical students. But basic science departments at academic institutions are hurting. They face challenges such as insufficient funding, dwindling faculty numbers, shrinking curriculum, and limited research space. Ultimately, these challenges negatively impact the medical field in a variety of ways.

Funding Issues

Basic science departments are predominantly funded by grants to support research. Typically, these departments don’t have a means to create revenue on their own, as clinical departments do through compensation for clinical work. “While there may be some state funding for specific investigators, these salary lines are few and far between and certainly aren’t enough to support a complete and modern department,” said Andrew Murr, MD, professor and chair of the department of otolaryngology–head and neck surgery at the University of California, San Francisco. “Endowed positions sometimes exist to help with support, but basic science departments have little interaction with the public, so raising money through philanthropy is less likely,” he added.

Although there have been significant improvements in the federal government’s budget for the National Institutes of Health (NIH) in recent years, when adjusted for inflation, the budget is still smaller than it was in 2003. “Basic scientists have experienced 15 years with no growth in available resources, with terrible pay lines from NIH and National Science Foundation grants,” said Ross McKinney, MD, chief scientific officer of the Association of American Medical Colleges (AAMC).

Wendell G. Yarbrough, MD, MMHC, a professor and chair of otolaryngology/head and neck surgery at the University of North Carolina at Chapel Hill, had similar sentiments. “Many NIH institutes are funding applications in the single-digit percentiles, and when grants are funded they oftentimes aren’t large enough for the proposed research to be completed,” he said. In addition, salary caps on NIH grants create another funding gap. Funding from clinical sources or schools of medicine are also under pressure due to decreased reimbursement for clinical activity, so making up for lost funding is particularly challenging.

Dr. Murr added that with funding becoming increasingly tight for NIH awards, the funding line is becoming more exclusive, so fewer young scientists can get comfortably and firmly established. Furthermore, “if a researcher has an extremely compelling grant but their institution’s environment isn’t devoted to their topic of interest, they may be left out of funding,” he said.

Wendell G. Yarbrough, MD, MMHCThe erosion of academic pursuits in schools of medicine risks the leadership roles that schools have held and will ultimately slow innovation that would benefit patients. —Wendell G. Yarbrough, MD, MMHC

Dwindling Faculty Numbers

Developing and maintaining fruitful collaborations among clinical and basic science researchers is critical to a strong research program—especially collaborations that lead to translational and clinical research that directly benefits patient outcomes, said Judy R. Dubno, PhD, director of research in the department of otolaryngology–head and neck surgery at the Medical University of South Carolina in Charleston. But both basic science and clinical researchers face challenges in dedicating effort to collaborations and translational research, given the pressure to maintain their individual research programs with funding and their clinical practices.

A thriving research program also requires a strong infrastructure, including administrative personnel to assist with grant management, continually growing and changing policy and regulatory requirements, and other essential administrative tasks essential for conducting research, all of which add to overhead costs, Dr. Dubno said.

Finally, there is an urgent need for basic science faculty, departments, and medical schools to support the unique requirements of physician–scientists, Dr. Dubno added. To ensure the continued growth of the science that underlies otolaryngology health and disease, basic science faculty in otolaryngology–head and neck surgery departments must fully participate in an enriched educational and scientific environment that values research and research training as high priorities.

Given the limited funding that medical schools receive and the low rates of grant awards, bridge funding, a form of temporary and immediate funding for investigators whose grants have lapsed, is becoming more commonplace. Consequently, faculty members may not be able to continue their research if bridge funding is not available, Dr. Yarbrough said.

Limited funding for research has resulted in little or no growth in the number of faculty in basic science departments. AAMC data show that there were roughly the same 20,000 faculty in basic science departments in toto across the United States over the last decade. In 2009, there were 18,526 basic science faculty, and in 2018 there were 19,732—a 7% increase. However, at the same time there was a 21% increase in the number of medical schools.

Figure 1. NIH Research Appropriations 1995–2019 in Current and Constant Dollars. Source: NIH

Figure 1. NIH Research Appropriations 1995–2019 in Current and Constant Dollars.
Source: NIH

A related challenge stems from the fact that the median age for a medical school faculty member as of 2015 was around 50. Although staffing shortages aren’t a current problem, aging faculty are holding positions that could be filled by more recent graduates, but those slots aren’t available due to caps on the number of tenure-track salary lines.

Furthermore, Dr. Murr pointed out that losing scientists to industry is commonplace. “The biopharmaceutical industry can often pick off successful professors who are well established or successful post docs who are daunted by the extraordinary costs and pressures to set up a laboratory,” he added.

Shrinking Curriculum

Historically, basic scientists taught medical students in the first two years of the medical school curriculum. The standard model was that a faculty member would give a few lectures and perhaps run a course in their area of expertise. Students learned information through lecturing, but most schools are now moving to models that involve team-based learning or a problems-based curriculum, and some schools have completely eliminated lectures. As a result, the medical student teaching justification for basic science faculty has diminished substantially, and some schools are shifting dollars from basic science departments to the medical student teaching program.

Dr. McKinney added that teaching graduate students in the basic sciences continues to be an important role for basic science departments, a function supported by tuition dollars and by grants. However, attrition of faculty at some graduate schools means that programs are losing the critical mass of faculty necessary to sustain a basic science graduate program.

The lack of stable, long-term funding also makes it difficult to build and expand new programs and recruit and retain basic science faculty, Dr. Dubno said.

On the positive side, doctoral degree graduates in the biomedical sciences are very employable, Dr. McKinney said. The majority of them go into jobs that aren’t within academia, but rather in industry, government, or research.

Space Limitations

Departments also struggle with limited availability of high-quality space for clinical and basic science laboratories, Dr. Dubno said. Additionally, available space is rarely co-located with space designated for clinical faculty or basic science faculty who work in different sub-disciplines, which reduces opportunities for effective collaborations among clinicians and basic science faculty. Similarly, equipment, up-to-date technologies, and necessary renovations may be lacking due to limited intramural or extramural funding.

The Greater Impact

The balance among clinical care, education, and research is being tilted toward clinical care—which is the major source of income for a school and its affiliated hospitals. This results in a lower emphasis on and fewer funds invested in the basic sciences. “The intermediate to long-term risk is that academic basic science departments become more marginalized with fewer investigators,” Dr. Yarbrough said. “The erosion of academic pursuits in schools of medicine risks the leadership roles that schools have held and will ultimately slow innovation that would benefit patients.”

Dr. McKinney said that huge opportunities to improve care in hearing restoration and communications disorders will require more knowledge of how the brain processes acoustic signals at everything from the cellular level to the neuronal networks that respond and interpret the information. “But if basic science departments suffer, progress will be limited,” he said.

Because they have close relationships with basic science departments through collaborative research, shared faculty, and curricula that emphasize the intersection of basic and clinical knowledge, otolaryngology departments will face challenges for maintaining academic and educational missions. “Diminution of basic departments will make these challenges more acute,” Dr. Yarbrough said. “Strong basic science departments within medical schools are needed to train the next generation of otolaryngologists and to partner with otolaryngology faculty to advance our understanding and treatment of diseases of the upper aerodigestive tract.”

Karen Appold is a freelance medical writer based in New Jersey.

Key Points

  • The balance among clinical care, education, and research is tilting toward clinical care.
  • Limited funding for research has resulted in little or no growth in the number of faculty in basic science departments.
  • The lack of long-term funding makes it difficult to build new programs.

Six Ways to Help Basic Science Departments Regain Vitality

Keeping basic science departments running optimally is a growing challenge, but experts say some things can be done to help them regain their strength. Here are six suggestions.

  1. Support funding for the NIH. “There have been meaningful, greater-than-the-rate-of-inflation increases in the NIH budget each year since 2015,” Dr. McKinney said. “That has helped to heal the damage done by years of inadequate funding.” But schools of medicine will need to continue to support basic science financially, because NIH grants have never paid the full cost of basic science research. NIH funding is critical for basic science, and without it there won’t be the types of new ideas necessary for translation into novel clinical applications.
  2. Form partnerships. Basic science departments can partner with industry and clinical departments to increase research portfolios that are closer to clinical implementation, which could open new funding sources, said Dr. Yarbrough. In addition, academic hospitals and centers within medical schools should continue to invest wisely in basic science departments.
  3. Promote effective communication. Teach students to communicate their research to others in a clear, concise way. “We need the public (taxpayers) to understand what basic scientists do,” Dr. McKinney said. “Their support is necessary to sustain the basic science culture.”
  4. Ask public relations offices to avoid hyped language. “Hype can ultimately hurt basic science departments,” Dr. McKinney said. “The public will lose trust in science if they’re constantly being bombarded with false claims like there’s a new cure for cancer. When taxpayers lose their faith, funding will dry up.”
  5. Train doctors of philosophy to be flexible. “Don’t just train doctors of philosophy to be the next generation of faculty, train them to be the next generation of researchers for whatever environment they may find themselves, such as academia, industry, or government,” Dr. McKinney said.
  6. Help develop better pathways for junior investigators. “We need to make it easier to have a good career in basic science,” Dr. McKinney added. “This means that schools need to provide adequate resources to financially support junior faculty until they’re able to get federal grant funding.”

ENT Today

New Consensus Statement on Balloon Dilation of the Eustachian Tube

The American Academy of Otolaryngology–Head and Neck Surgery recently published a set of clinical statements on the indications for and appropriate use of balloon dilation of the Eustachian tube (BDET) for adult patients (aged 18 years and older) with obstructive Eustachian tube dysfunction (OETD). Published June 4, 2019 in Otolaryngology-Head and Neck Surgery, “Clinical Consensus Statements: Balloon Dilation of the Eustachian Tube” was compiled by a panel of experts in response to the increasing rates of use of this technology for treatment of OETD by otolaryngologists and the need for some guidance given evidence gaps regarding its use.

“Balloon dilation of the Eustachian tube holds promise for the management of OETD, but because it is new territory for most clinicians an official statement was deemed necessary to reduce variations in care and prevent misapplication of this technology,” said Edward D. McCoul, MD, MPH, associate professor and director of rhinology and sinus surgery in the department of otorhinolaryngology at the Ochsner Clinic in New Orleans and a coauthor of the statement. “This statement calls attention to the current state of the literature as interpreted by experts in the field.”

The consensus statement offers 28 specific points of guidance categorized into the areas of patient criteria, perioperative considerations, and outcomes. Dr. McCoul highlighted a number of key areas he thought may be new to otolaryngologists and therefore particularly useful.

Patient criteria: Accurate diagnosis of OETD prior to considering BDET is critical given the variable and nonspecific symptoms that patients may present with. Along with a careful history, the panel emphasized the need to identify any underlying extrinsic causes of OETC such as allergic rhinitis, rhinosinusitis, and laryngopharyngeal reflux for which targeted treatment could also improve OETC. If any of these comorbid conditions are found, the panel recommends treating them prior to offering BDET.

The panel also emphasized the need for nasal endoscopy prior to consideration of BDET. “Nasal endoscopy and tympanometry are important to include when evaluating a patient for the presence of OETD,” said Dr. McCoul, underscoring the need to rule out other causes of ear fullness, including patulous Eustachian tube dysfunction.

Perioperative considerations: The panel underscored that tympanostomy tube placement is not a mandatory prerequisite for performing BDET. In addition, the panel stated that BDET should be considered an alternative to tympanostomy tube placement for treating OETD.

Outcomes: To determine outcomes, the panel noted the most reliable outcome measure is a standardized questionnaire (the Eustachian Tube Dysfunction Questionnaire-7) to record patient-reported symptoms using.
The statement also discusses and highlights clinical areas for which no consensus could be reached. Dr. McCoul highlighted a few: the extent of optimal medical therapy prior to offering BDT remains unclear, and additional objective outcome measures are still needed.

Overall, the consensus statement offers clinicians a guide to what experts currently agree on regarding the role and implementation of BDET for OETD. The authors hope that application of the statements will reduce variation in how BDET is currently used for OETD and increase the quality of care.

ENT Today

Comparison of Running Cutaneous Suture Spacing During Linear Wound Closures

Comment: This paper compares spacing of sutures and found no difference between those placed 2 mm and 5 mm apart. The closures examined were from surgical fusiform wounds. Of course, this is not analogous to the traumatic wounds encountered on call, but is food for thought, especially considering the time involved in placement of very fine sutures with no obvious cosmetic benefit (at least at three months).—Jennifer A. Villwock, MD

What are the outcomes and wound cosmesis achieved with running cutaneous sutures spaced 2 mm vs. 5 mm apart?

Bottom Line: No statistically significant difference in wound cosmesis or total complications were noted between running cuticular sutures spaced 2 mm vs. 5 mm apart. Both suturing techniques resulted in similar cosmetic outcomes and complication rates. Surgeons may want to consider whether the extra time involved in placing very closely spaced cuticular sutures is worthwhile.

Background: Surgeons have varying opinions on the ideal cutaneous suture spacing for optimal cosmetic outcomes. To date, no studies concerning the effect of suture spacing on cosmetic outcomes exist in the literature.

Study design: Randomized clinical trial.

Setting: University of California, Davis dermatology clinic.

Synopsis: The trial was conducted from November 28, 2017, to June 15, 2018. Fifty-six patients 18 years or older with surgical fusiform wounds (from Mohs procedure or surgical excision) on the head or neck with assumed closure lengths of at least 3 cm were screened. Resarchers excluded six patients, enrolled 50 patients, and followed up with 48 patients. Fifty surgical fusiform wounds were randomized to running cuticular closure with 2-mm spacing on half and 5-mm spacing on half. At three months, patients and two masked observers evaluated each scar using the patient and observer scar assessment scale (POSAS). A total of 50 patients (mean [SD] age, 71.1 [11.4] years; 43 [86%] male; 50 [100%] white) were enrolled in the study. The mean (SD) sum of the POSAS observer component scores was 10.7 (4.3) for the 2-mm interval side and 10.8 (3.5) for the 5-mm side at three months. No statistically significant difference was found in the mean (SD) sum of the patient component for the POSAS score between the 2-mm interval side (10.2 [4.7]) and the 5-mm interval side (11.5 [6.4]) at three months. No statistically significant difference was observed in mean (SD) scar width between the 2-mm side (0.9 [0.6] mm) and the 5-mm side (0.8 [0.4] mm).

Citation: Sklar LR, Pourang A, Armstrong AW, et al. Comparison of running cutaneous suture spacing during linear wound closures and the effect on wound cosmesis of the face and neck: a randomized clinical trial [published January 16, 2019 online ahead of print]. JAMA Dermatol. doi: 10.1001/jamadermatol.2018.5057.

ENT Today

Timothy Smith Appointed Editor-In-Chief of IFAR

In May 2020, Timothy L. Smith, MD, MPH, will succeed David W. Kennedy, MD as editor-in-chief of the journal The International Forum of Allergy & Rhinology (IFAR).

Published by Wiley and launched in 2011, IFAR is the official publication of the American Rhinologic Society and the American Academy of Otolaryngic Allergy. Dr. Smith brings extensive experience IFAR. “I am acutely aware of the challenges researchers face and extensive efforts they put forth in the quest to advance our knowledge and our specialty,” said Dr. Smith. “I will lead a review process that is fair, impartial, and collegial, and one that identifies the best work deserving of publication and serves its readership.”

Dr. Smith is Professor and Vice Chair in the department of otolaryngology–head and neck surgery at the Oregon Health & Science University and an active member in a number of professional organizations. He is a Past President of the American Rhinologic Society, has been elected to the Board of Directors for the American Academy of Otolaryngology–Head and Neck Surgery and to the American Board of Otolaryngology–Head and Neck Surgery, and has served on the editorial boards of numerous otolaryngology journals and publications including as an associate editor for IFAR, JAMA Otolaryngology–Head and Neck Surgery, and ENTtoday. Dr. Smith has also published more than 300 peer-reviewed articles and other scientific publications.

Dr. Smith emphasized that he will work toward maintaining and growing the strong reputation of IFAR. “IFAR will be the informational centerpiece for cutting edge discovery and innovation, best practices, and commentary and debate, for clinicians and researchers worldwide with interest in the fields of rhinology, endoscopic cranial base, otolaryngic allergy, and associated disorders,” he said.

ENT Today

Should the Contralateral Tonsil Be Removed in Cases of HPV-Positive Squamous Cell Carcinoma of the Tonsil?

TRIO Best PracticeTRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope.


Human papillomavirus-positive (HPV+) head and neck squamous cell carcinomas (SCC) are increasing in incidence worldwide. The palatine tonsils are the most commonly involved anatomical subsite, followed by the base of tongue and then the soft palate. Secondary primary malignancy (SPM) is a well-established phenomenon among patients with head and neck SCC and can present in up to 36% of patients within 20 years of their original diagnosis. Furthermore, synchronous tumors are defined as those that occur simultaneously with the index cancer; these tumors are present in approximately 4% of cases.

SPM is thought to arise secondary to field cancerization, a biological process by which prolonged exposure to carcinogens leads to independent malignant transformation at multiple sites. The prevalence of synchronous bilateral HPV+ SCC of the tonsil (SBTC) is largely unknown, and there is much controversy regarding routinely removing the contralateral tonsil. Fear of increased pain, bleeding, circumferential scarring, and functional impairment have all been cited as reasons to avoid contralateral tonsillectomy in these scenarios. Proponents of contralateral tonsillectomy, however, raise concerns over the potentially fatal consequences of missing occult contralateral disease. Another advantage is the resulting symmetric appearance of the palatal arches, which allows for improved oncologic surveillance and easier detection of tumor recurrence.

Given the important prognostic and therapeutic implications of identifying a SBTC, should the contralateral tonsil routinely be removed in cases of HPV+ squamous cell carcinoma of the tonsil (TSCC)?

Best Practice

The contralateral tonsil should routinely be removed in cases of suspected or known unilateral HPV+ TSCC. Furthermore, preoperative clinical exam findings and imaging studies including PET-CT should not be used to exclude the possibility of SBTC. Although there are reports of significant complications resulting from bilateral radical surgery, performing a routine contralateral tonsillectomy does not appear to increase rates of morbidity or complications, and the resulting symmetric palatal arch could potentially improve oncologic surveillance and detection of recurrence.

Furthermore, identifying a contralateral TSCC can dramatically alter treatment and prognosis. The patient may need further surgery and/or radiation therapy to the contralateral oropharynx and neck, which otherwise would not be indicated in unilateral disease. Although the true incidence of SBTC remains unknown, the oncologic outcome of missing the second primary and delaying treatment can be devastating and even fatal. Future prospective studies should be performed to identify any clinical disparities or differences in tumor characteristics that could improve preoperative identification of SBTC patients (Laryngoscope. 2019;129:1257–1258).

ENT Today

New Research and Education at COSM 2019

AUSTIN, Texas—In May, Triological Society members and other attendees came together for the society’s 122nd Annual Meeting to share research and foster new ideas within the field of otolaryngology. The 2019 Triological Society Annual Meeting, held in conjunction with the Combined Otolaryngology Spring Meetings (COSM), welcomed 470 attendees plus residents and medical students, who joined discussions, heard panelists debate, and viewed an extensive array of scientific posters.

Nearly 900 residents and medical students attended COSM, many of whom were offered the opportunity to present clinical and research papers and posters during the society meetings. “I attended the conference to learn about the newest developments in otology and to support the excellent work of some of the medical students and residents with whom I work,” said Aaron Moberly, MD, an assistant professor in the division of otology, neurotology, and cranial base surgery in the department of otolaryngology–head and neck surgery at  The Ohio State University Wexner Medical Center in Columbus.

During the Triological Society’s scientific sessions, 65 podium presentations and seven panels were given. More than 160 posters were presented as a part of a combined poster session. The Triological Society again funded travel grants to fellows, residents, and medical students selected to present oral and poster presentations during the Society’s scientific sessions.

Presidential Address: A Patient’s Perspective on HNC

Sigsbee Duck, RPh, MD, said that he has had an incredible year as the president of the Triological Society. His presidential speech was made “to simply remind all otolaryngologists how important empathy and caring are for our cancer patients. I am just laying out the stark and personal reality of being a head and neck cancer patient first hand and the feelings associated with the treatment process.” He went on to thank all of his head and neck surgery colleagues who selflessly care for patients like him on a daily basis.

Dr. Duck definitely understands the importance of empathy and caring for cancer patients, as he himself is a head and neck cancer survivor. “On the morning of March 9, 2015, I was getting ready for work, shaving actually, when I felt a mass in my right upper neck. Denial set in and I convinced myself that it was an infection.” He put himself on antibiotics and after a few doses he realized it was not going down and seemed to be larger. Becoming quite concerned, he called the Huntsman Cancer in Salt Lake City and drove three hours from Wyoming the same Thursday for a biopsy. The physician told him the ultrasound characteristics appeared benign and to come back in one month if the mass was still present for a FNA. He responded, “I’m here now, so please proceed.” He did and the next Monday the endocrinologist called to inform him “you have metastatic epidermoid carcinoma.” Reality quickly set in.

“This couldn’t be happening to me,” Dr. Duck thought. He was asked to be back at the Huntsman on Wednesday for a PET scan, but as he had NCAA basketball tournament tickets in Kentucky the following weekend, he opted to wait a week and meet his family to let the reality of a totally surrealistic situation settle in. The next week the PET scan was completed. With his surgeon, Dr. Jason Hunt’s hand on his shoulder, he was informed he had a “large tonsillar carcinoma with neck metastasis.”

Dr. Duck underwent a radical tonsillectomy and a modified RND the next day. “I was still in denial,” he said. “Five hours later reality took hold when I awakened to find an NG tube, a Foley, a JP drain, an IV between the toes on my right foot, an inability to swallow and complete anesthesia from my mid cheek to my clavicle. When I finally woke up, reality once again hit and I sat up with a very kind nurse and cried for about three hours. Then came swallowing therapy and ultimately tubes were removed one at a time as my wife and I waited for the pathology reports to assure clear margins and positive testing for HPV and P-16.” He was blessed to have these findings. The day he left the hospital, a Basset Hound therapy dog came by to visit and he realized that “it’s the small things that really mean the most to patients.”

Sigsbee W. Duck, MDAs physicians, we must take extra time with our cancer patients. We must show genuine empathy. —Sigsbee W. Duck, MD

“Emotions run amuck while going through cancer treatment and they are very difficult to control,” Dr. Duck found out. “When I finally returned to work in Wyoming prior to radiation therapy, I was not successful—or nice. I was curt and downright rude. I had not realized the emotional toll cancer takes on patients.”

Radiation therapy was next. “Despite having sent hundreds of patients for these treatments, it was at this point that I realized that I really didn’t know anything about it. Now, more than ever, I genuinely admire my cancer patients, particularly the ones without the financial means or family support like I was blessed to have who must complete this therapy.” Dr. Duck recalled an older man who sat next to him before his first radiation treatment. “He had been told his radiation was palliative and to get his affairs in order. He asked why I was there and I told him and he said good luck. The next day, he was not there and I never saw him again. It is sad and disconcerting to see all these patients every day, and suddenly they are not there anymore.”

On his last day of radiation, the waiting room was full and he was informed that the machine was down. “I figured my options were to get mad, sulk, or cry. Well, I’m a crier,” he said. The other patients with whom he had bonded huddled around him for support, the machine was ultimately repaired and with radiation therapy completed, he finally left the Huntsman.

Dr. Duck’s long and emotionally difficult experience with surgery and radiation were not only grueling, but also educational. “The post-traumatic effects of surgery and radiation therapy, especially as radiation is over-utilized to treat this disease, particularly when used in conjunction with chemotherapy, are very real,” Dr. Duck stated. “And radiation is definitely the gift that keeps on giving—for the rest of your life. Your taste is permanently altered, you have pain and cramping with exercise, and you can never taste or swallow effectively.”

“And there is a stigma associated with HPV H&N cancer. Even my colleagues make jokes about sexual transmission. I had been married for 33 years, and I found no humor in their jokes,” he said. “Frankly, who knows what  bacteria any of us are harboring as otolaryngologists? My entire family has been tested and cleared and we have received the HPV vaccine including the P-16 and P-18 strains.

“No matter how many H&N cancer patients  you have cared for, always remember the absolute feelings of fear and helplessness that your patients experience. As physicians, we must take extra time with our cancer patients. We must show genuine empathy. Sit down by the bed as if you are not busy. These days, I share my experience with my patients and it reassures them in a positive way.” Dr. Duck added. “Most importantly, an opportunity to convey information to a patient’s family and exude a feeling of optimism and trust as to the care we are taking of their loved ones, is one of the greatest opportunities we have as physicians—to demonstrate compassion and caring through simple communication and basic kindness.”

Dr. Duck’s hard-earned message is this: “As cancer patients we are always looking over our shoulders; fear, anxiety, and reality are always lurking. More than ever [these patients] need a physician who is sensitive to that reality and who can show genuine empathy and caring.” 

Elizabeth Hofheinz is a freelance medical writer based in Louisiana.

Upcoming Triological Society Meetings

Combined Sections Meeting
January 23-25, 2020
Coronado, Calif.

123rd Annual Meeting at COSM
April 24-25, 2020
Atlanta, Ga.

Visit for more information.

ENT Today

Tips to Help You Regain Your Sense of Self

When I was 10, my family and I lived in rural Pennsylvania. I had three siblings and we made our own fun. We climbed trees, made friends with spiders, and played with the neighbor’s horse until the fence broke and it almost stepped on my baby brother. We mostly played outside to stay out of trouble, but inside could be equally entertaining. There were inside rules—no running, quiet voices, no bouncy ball—which were sometimes circumvented, but almost universally obeyed.

One day, left to my own devices, 10-year-old me disobeyed one of the more sacrosanct decrees of my household: Thou shalt not climb on the cabinets. My need for fun eclipsed my innate desire to follow the rules and up, up, up I went. A moment basking in the glow of my success was followed by panic. My mom was on the porch and would enter the house momentarily. I jumped. White hot pain exploded in my left foot. It had landed, big toe first, in an open box of Legos. I stifled a scream and fell to the floor. “What on earth is going on?” my mom asked. “I think I stubbed my toe,” I lied.

My parents were confused as to how a stubbed toe could cause so much pain, as were the emergency department physicians who evaluated me when my agony had not subsided several hours later. However, I was now committed to my lie and kept retelling the same story. We were reassured that nothing was wrong. My stubbed big toe would heal up just fine on its own. And heal it did, only an inch shorter and fused at the proximal and distal interphalangeal joints. I am reminded of my trivial childhood decision to lie every time I put on a pair of shoes, one of which will forever either be too big or too small. It makes me wonder if the truth and a plaster cast may have been the better option. I also wonder how, without the benefit of time, wisdom, and retrospection, we can know this in advance.

For me, this is also true when it comes to the decisions we make daily. Some decisions are like a mask we put on. Ten-year-old me wanted her “good girl,” rule-following mask to stay intact more than she wanted to have her toe properly addressed. That same year, we fifth graders were eligible to join the school band. During an informational session, they told us that the flute was one of the more difficult instruments to learn. I heard nothing else; that was all I needed to know. Another layer of my mask at the time was proving that I could excel at all the difficult things. Flute it was, regardless of whether or not another instrument would have brought me more joy. The elements of our masks may be genetic, learned, taught, or arise from trauma or other experiences. They are almost always well intentioned.

However, I believe that the mask analogy isn’t entirely accurate. These things do not make up our masks; they make up our casts. They are put on to protect us or to help us move with more ease through our circumstances. There are plenty of resources available to show us how to add layers to our casts. Facebook and Instagram have taught a generation to post smiling pictures showcasing “Living Your Best Life.” The importance of this careful curation of visual snippets of your life is to project the image of who you want the world to think you are. Peeling away the layers and exposing what’s underneath is not nearly as publicized or glamorous.

Jennifer A. Villwock, MDI was really struggling then too. I didn’t have anyone to talk to because everyone seemed to have all their stuff together except me. If only we had known, we could have probably really helped each other. —Jennifer A. Villwock, MD

I recently gave a local TEDx talk. Some of what I said you might have read before in my last wellness column (ENTtoday. 2018;13:1). Some of it was new. The gist of the talk was about the importance of the stories we tell ourselves about our experiences, illustrated by examples from my life as a surgeon. Some people told me my talk moved them to tears. Several that knew me during the difficult stages in my life that I talked about said, “I was really struggling then too. I didn’t have anyone to talk to because everyone seemed to have all their stuff together except me. If only we had known, we could have probably really helped each other.” I didn’t say anything that most of us haven’t experienced. I just peeled back a tiny bit of one of my casts.

So what happens if you don’t take a cast off or if you don’t know how? It gets itchy. Probably a little smelly too. The strength underneath can atrophy, the skin turning pale. As time progresses, it can take not only an increasing amount of effort, but also courage, to try and take off the cast. Because of this, we may elect to accept the itch. I wonder if more of us were willing to peel back our casts with an attitude of, “Hey, look at this. Isn’t this strange, but also normal considering what we’ve been through? Won’t it be cool to watch this limb rehabilitate and be strong again?”—would we all be healthier as a community?

Because the location and substance of our casts can be so different, generic one-size-fits-all wellness advice can fall short. For example, online wellness modules are typically not universally well received. At best, one size fits some. Additionally, this type of well-intentioned advice can be counterproductive. If you absolutely cannot sit still, hearing that you need to do sitting meditation daily may just create stress and angst and another plaster layer on your cast as you try to comply. Similarly, I dislike running; my marathon-running partner is my exercise-kryptonite. The “couples who sweat together, stay together” mantra does not apply to us; trying to follow it would harm our relationship.

Do you know where your casts end and your own skin begins? As you head to bed and reflect on your day, maybe catching a glimpse of yourself in the mirror, do you ever get that nagging sensation that you’re not who you wanted to be? Great news! This is your own subtle call to action and tomorrow is another opportunity to be the better person you had hoped you would be today. The only question now is what to do with that sensation. Perhaps consider answering the following questions for yourself and experiment with implementing the answers in your own life:

  • What foods do you actually enjoy eating that also healthfully fuel your body? Eat those things. If you don’t know, ask for help. Your health insurance may include free health coaching or nutrition perks. Maybe organize a healthy potluck or meal exchange.
  • What activities do you enjoy that move your body and keep you active? Do more of that. If you don’t know, consider signing up for a random class or take advantage of a Groupon offer.
  • Feeling too introverted or embarrassed for an exercise class? Sign up for a two-week free trial of one of the many exercise apps available.
  • Do you have a hobby or interest? Nurture it. Can’t remember what you find fun? Ask a friend or colleague for a recommendation or to come with you to a random community event. (I recommend children’s musical theater. There are few things cuter than a multitude of 5-year olds singing Disney songs!)
  • Do you like to create? Decide to make something and, if you don’t already know how, watch a YouTube video and learn (if you’re interested in crochet, check out Wooly Wonders crochet channel ϑ). If you realize you hate the process halfway through, give yourself permission to quit!
  • What new horizons would you like to explore through music or literature? Ask a friend if they’ve come across any up and coming artists or find an open mic night. Maybe join, or start, a book club.

And to you medical students and residents reading, or anyone else who’s overwhelmed with their exceptionally busy life, actively thinking to yourself, “I do not have the time, or the money, for any of your suggestions,” I see you. I hear you. I understand. Perhaps a follow-up question to the ones above may be, “What is the smallest next step I can take towards those goals?” Could you carry almonds or other nuts in your white coat pocket to have a healthy snack option? Can you commit to taking the stairs up one more flight of stairs than you normally would while rounding on patients? Can you sneak away for five minutes in between consults to go stand in a patch of sunlight and take 10 deep breaths? Could you focus on having one genuine, human interaction with another person per day?

As you consider these options, be kind to yourself as you experiment. Not everything is going to feel “right.” It may take some time to remember who you are under all the layers and after all the years of focusing on your training and the welfare of others. Try to avoid “should-ing all over yourself” and doing things out of guilt because they’re what you think you’re supposed to do, lest they drain you while adding another layer of plaster.

“Love takes off casts* that we fear we cannot live without and know we cannot live within.”—James Baldwin

*original quote: “Love takes off masks…” 

Dr. Villwock is an assistant professor of  otolaryngology–head and neck surgery in the division of rhinology and skull base surgery at the University of Kansas Medical Center in Kansas City. She is also a member of the ENTtoday editorial advisory board.

Call to Action

How you can explore your sense of self:

  • Sign up for a class or take advantage of a Groupon offer.
  • Organize a healthy potluck or meal exchange.
  • Sign up for a trial with one of the many exercise apps available.
  • Ask a friend or colleague to accompany you to a random community event.
  • Decide to make something and, if you don’t already know how, watch a video online.
  • Join—or start—a book club.
  • If you know you don’t like something, allow yourself to say no, and try to let go of feeling guilty.

ENT Today

Is Core Needle Biopsy Effective for Assessment of Head and Neck Lesions?

TRIO Best PracticeTRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope.


Ultrasonography in combination with fine needle aspiration (FNA) has served as the primary line of investigation for head and neck lesions. In the 10% to 15% of cases for which FNAs yield nondiagnostic material, the next option is often excisional biopsy under general anesthesia. In patients who are poor surgical candidates, core needle biopsy (CNB) with a larger gauge needle under ultrasound guidance has emerged as a simple, minimally invasive, and accurate method for the diagnosis of head and neck lesions, especially when conservative treatment is likely. CNB has been shown to yield a higher sensitivity and specificity compared to FNA in head and neck lesions, including malignant lymphoma. Surveys show physicians are reluctant to incorporate this diagnostic method into practice due to concerns regarding bleeding, infection, nerve injury, and tumor cell seeding. This article reviews the evidence for the safety of CNB in the diagnosis of head and neck lesions, with an emphasis on the risk of tumor cell seeding and bleeding.

Best Practice

Based on current studies, ultrasound guided CNB is a minimally invasive and accurate diagnostic option for the assessment of head and neck lesions, including lymphoma. In comparison to FNA, CNB has achieved a higher accuracy in providing specific diagnoses, detecting malignancy, and identifying true neoplasms. CNB should be the procedure of choice in patients with multiple nondiagnostic FNAs prior to excisional biopsy. These studies have shown that CNB has enhanced accuracy and equivalent safety compared to FNA and lower rates of complications as compared to excisional biopsy (Laryngoscope. 2018;129:2669–2670)

ENT Today

Mild Obstructive Sleep Apnea in Children: What Is the Best Management Option?

TRIO Best PracticeTRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope. May 2019


Pediatric obstructive sleep apnea (OSA) is characterized by upper airway obstruction, poor sleep, and daytime sequelae such as hyperactivity. Although controversy exists regarding the ideal evaluation for children with sleep-disordered breathing, the severity of OSA is currently determined by full-night polysomnogram (PSG). Mild OSA is defined by an apnea-hypopnea index (AHI) > 1 and <5. The majority (approximately 85%) of healthy school-aged children evaluated by otolaryngologists for tonsil hypertrophy and obstructive symptoms have either primary snoring or nonsevere OSA.

The treatment of mild OSA in children is controversial. There is a lack of data on the natural history of mild sleep apnea. Furthermore, a poor correlation exists between quality of life (QOL) scores and OSA severity; mild OSA in children may have a significant impact on their general health and well-being. High-quality studies comparing observation, medical management, and surgery for mild pediatric OSA are just beginning to emerge. Many of these studies use varied measures to assess outcomes. Thus, it may be difficult for providers treating children with mild OSA to counsel parents on the optimal treatment for their child.

Best Practice

Multiple therapeutic options may be effective for treating mild pediatric OSA including observation, management with anti-inflammatory medications, and surgery (Table 1). Validated instruments that assess symptom burden and the impact of OSA on QOL may be useful in determining which treatment option is most appropriate for the child. Shared decision making between caregiver, child (when appropriate), and physician may be useful in developing a management strategy for mild OSA. Data on the sequelae of mild OSA in children, including the impact of obstruction on cardiovascular parameters and neurocognition, are lacking. Future research is needed to compare long-term outcomes for the different treatment options for mild OSA in children (Laryngoscope. 2018;128:2671–2672).

ENT Today