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This Viewpoint addresses the lack of reimbursement for olfactory testing, which is especially important in a time when the populations of older adults and patients with COVID-19–associated olfactory dysfunction have grown.

Endoscopic endonasal skull base surgery (EESBS) is the preferred surgical approach for the management of pituitary adenomas. Perioperative management of pituitary lesions requires multidisciplinary care, and typically includes a dual surgeon team consisting of a neurosurgeon and an otolaryngologist. The involvement of the otolaryngologist allows for a safe surgical approach with excellent intraoperative visualization of the tumor to enable an effective resection of the tumor by the neurosurgeon. Detection and treatment of sinonasal pathology is essential prior to surgery. Patients may experience sinonasal complaints following endoscopic transsphenoidal surgery, although this is typically temporary. Sinonasal care in the postoperative period can expedite recovery to baseline. Here, we discuss the perioperative factors of endoscopic pituitary surgery that endocrinologists should be aware of, ranging from preoperative patient selection and optimization to postoperative care, with a particular emphasis on anatomic and surgical factors.

OBJECTIVE Suprasellar meningioma resection via either the transcranial approach (TCA) or the endoscopic endonasal approach (EEA) is an area of controversy and active evaluation. Skull base surgeons increasingly consider patient-reported outcomes (PROs) when choosing an approach. No PRO measure currently exists to assess quality of life for suprasellar meningiomas. METHODS Adult patients undergoing suprasellar meningioma resection between 2013 and 2019 via EEA (n = 14) or TCA (n = 14) underwent semistructured interviews. Transcripts were coded using a grounded theory approach to identify themes as the basis for a PRO measure that includes all uniquely reported symptoms. To assess content validity, 32 patients and 15 surgeons used a Likert scale to rate the relevance of items on the resulting questionnaire and the general Patient-Reported Outcomes Measurement Information System–29 (PROMIS29). The mean scores were calculated for all items and compared for TCA versus EEA patient cohorts by using unpaired t-tests. Items on either questionnaire with mean scores ≥ 2.0 from patients were considered meaningful and were aggregated to form the novel Suprasellar Meningioma Patient-Reported Outcome Survey (SMPRO) instrument. RESULTS Qualitative analyses resulted in 55 candidate items. Relative to patients who underwent the EEA, those who underwent the TCA reported significantly worse future outlook before surgery (p = 0.01), tiredness from medications 2 weeks after surgery (p = 0.001), and word-finding and memory difficulties 3 months after surgery (p = 0.05 and < 0.001, respectively). The items that patients who received a TCA were most concerned about included medication-induced lethargy after surgery (2.9 ± 1.3), blurry vision before surgery (2.7 ± 1.5), and difficulty reading due to blurry vision before surgery (2.7 ± 2.7). Items that patients who received an EEA were most concerned about included blurry vision before surgery (3.5 ± 1.3), difficulty reading due to blurry vision before surgery (2.4 ± 1.3), and problems with smell postsurgery (2.9 ± 1.3). Although surgeons overall overestimated how concerned patients were about questionnaire items (p < 0.0005), the greatest discrepancies between patient and surgeon relevance scores were for blurry vision pre- and postoperatively (p < 0.001 and < 0.001, respectively) and problems with taste postoperatively (p < 0.001). Seventeen meningioma-specific items were considered meaningful, supplementing 8 significant PROMIS29 items to create the novel 25-item SMPRO. CONCLUSIONS The authors developed a disease- and approach-specific measure for suprasellar meningiomas to compare quality of life by operative approach. If demonstrated to be reliable and valid in future studies, this instrument may assist patients and providers in choosing a personalized surgical approach.

Background: The literature regarding clinical olfaction, olfactory loss, and olfactory dysfunction has expanded rapidly over the past two decades, with an exponential rise in the past year. There is substantial variability in the quality of this literature and a need to consolidate and critically review the evidence. It is with that aim that we have gathered experts from around the world to produce this International Consensus on Allergy and Rhinology: Olfaction (ICAR:O). Methods: Using previously described methodology, specific topics were developed relating to olfaction. Each topic was assigned a literature review, evidence-based review, or evidence-based review with recommendations format as dictated by available evidence and scope within the ICAR:O document. Following iterative reviews of each topic, the ICAR:O document was integrated and reviewed by all authors for final consensus. Results: The ICAR:O document reviews nearly 100 separate topics within the realm of olfaction, including diagnosis, epidemiology, disease burden, diagnosis, testing, etiology, treatment, and associated pathologies. Conclusion: This critical review of the existing clinical olfaction literature provides much needed insight and clarity into the evaluation, diagnosis, and treatment of patients with olfactory dysfunction, while also clearly delineating gaps in our knowledge and evidence base that we should investigate further.

Despite the significant morbidity associated with chronic rhinosinusitis in individuals with asthma (CRSwA) there is a paucity of codified, evidence-based management strategies for CRS in this population.Using PubMed, EMBASE, and Cochrane Review Databases, a systematic review was performed covering management strategies for CRSwA. 5,903 articles were screened; 70 were included for full-text analysis. After application of exclusion criteria, 53 articles comprised the qualitative synthesis. The level of evidence was graded, and benefit-harm assessments, as well as value judgment and recommendations were provided RESULTS: : Strong evidence confirms the benefit of oral and topical medications on sinonasal-specific outcomes in individuals with CRSwA; there is low-grade evidence demonstrating that these agents improve lung function and/or asthma control. Moderate-to-strong evidence suggests that endoscopic sinus surgery (ESS) improves both sinonasal- and asthma-specific quality of life. Although there is insufficient-to-low evidence to indicate that ESS improves pulmonary function in this population, data indicate a positive impact of this intervention on asthma control. Biologic medications strongly improve both subjective and objective sinonasal- and asthma-specific outcomes.Evidence supports managing CRS in individuals with CRSwA in a stepwise fashion, starting with traditional non-biologic oral and topical medication, and escalating to second-line treatments, such as ESS and biologics. Optimal treatment of individuals who suffer from CRSwA often requires concurrent, directed management of asthma, as not all CRS interventions impact asthma status. This article is protected by copyright. All rights reserved.

Frailty is a syndrome characterized by reduced physiologic reserve and increased vulnerability to poor health outcomes. Disruption of sensorineural function appears to serve as a novel biomarker of frailty. Using population-level data, we sought to characterize the association between otolaryngic sensory dysfunction and frailty.A cross-sectional analysis of the 2011-2012 US National Health and Nutrition Examination Survey was performed on adults ≥40 years of age (n = 2138). Participants were grouped by subjective gustatory dysfunction (sGD), olfactory dysfunction (sOD), hearing loss (sHL), and measured hearing loss (mHL) with pure tone averages (PTAs). Frailty was operationalized using a continuous 36-item frailty index (FI) scored from 0 to 1, stratified in 4 categories ("non-frail," "vulnerable," "frail," or "most frail").All sensory loss groups had significantly higher FI scores than those without sensory loss (sGD = 0.15; sOD = 0.14; sHL = 0.15; low-frequency mHL = 0.16; high-frequency mHL = 0.14 vs control = 0.11; p 0.007 for all). "Vulnerable" individuals had increased odds of sOD (adjusted odds ratio [aOR], 1.45; 95% confidence interval [CI], 1.05-2.00), whereas "frail" individuals had increased odds of sOD (aOR, 1.85; 95% CI, 1.26-2.71) and low-frequency mHL (aOR, 4.01; 95% CI, 1.27-12.63). The "most frail" individuals had increased odds of sHL (aOR, 11.72; 95% CI, 2.88-47.66) and high-frequency mHL (aOR 5.10; 95% CI, 1.72-15.12). PTAs were linearly associated with FI (low: β = 10.15; 95% CI, 1.78-18.51; high: β = 19.85; 95% CI, 5.19-34.53).Otolaryngic sensory loss is associated with increased frailty. Independent association of frailty with measures of olfaction and hearing suggests that olfactory and hearing assessments may help identify at-risk individuals with modifiable risk factors.

Hemorrhagic hereditary telangiectasia (HHT) is a rare autosomal dominant disorder that causes multisystem vascular malformations including mucocutaneous telangiectasias and arteriovenous malformations (AVMs). Clinical and genetic screening of patients with signs, symptoms, or a family history suggestive of HHT is recommended to confirm the diagnosis on the basis of the Curaçao criteria and prevent associated complications. Patients with HHT frequently have epistaxis and gastrointestinal bleeding from telangiectasias. Pulmonary AVMs are common right-to-left shunts between pulmonary arteries and veins that can result in dyspnea and exercise intolerance, heart failure, migraine headaches, stroke or transient ischemic attacks, brain abscesses, or in rare cases, pulmonary hemorrhage. Primary neurologic complications from cerebral AVMs, which can take on many forms, are less common but particularly severe complications of HHT. Multimodality imaging, including transthoracic echocardiography, Doppler US, CT, and MRI, is used in the screening and initial characterization of vascular lesions in patients with HHT. Diagnostic angiography is an important tool in characterization of and interventional treatments for HHT, particularly those in the lungs and central nervous system. A multidisciplinary approach to early diagnosis, treatment, imaging, and surveillance at high-volume HHT Centers of Excellence is recommended. Although a variety of idiopathic, traumatic, or genetic conditions can result in similar clinical and imaging features, the Curaçao criteria are particularly useful for the proper diagnosis of HHT. Imaging and treatment options are reviewed, with a focus on screening, diagnosis, and posttreatment findings, with the use of updated international guidelines.

Considering quality of life (QOL) is critical when discussing treatment options for patients undergoing endoscopic endonasal skull base surgery (EESBS) for cancers at the base of the skull. Several questionnaires have been developed and validated in the last 20 years to explore QOL in this patient population, including the Anterior Skull Base Questionnaire, Skull Base Inventory, EESBS Questionnaire, and the Sino-Nasal Outcome Test for Neurosurgery. The Sino-Nasal Outcomes Test-22 and Anterior Skull Base Nasal Inventory-12 are other tools that have been used to measure sinonasal QOL in anterior cranial base surgery. In addition to pathology-related perturbations in QOL endoscopic surgical options (transsellar approaches, anterior cranial base surgery, and various reconstructive techniques) all have unique morbidities and QOL implications that should be considered. Finally, we look ahead to new and emerging techniques and tools aimed to help preserve and improve QOL for patients with anterior cranial base malignancies.

Background Olfactory impairment is increasingly recognized as a biomarker of frailty, but the relationship between olfactory subdomains that describe peripheral or central dysfunction and frailty remains unexplored. Methods We examined 1 160 older adults from the National Social Life, Health, and Aging Project Wave 3. Olfactory identification (OI): the ability to identify an odorant; and olfactory sensitivity (OS): the ability to detect the presence of an odorant, were assessed using 5- and 6-point measures, respectively. Frailty was operationalized as both a 37-item frailty index (FI) and the 5-item Physical Frailty Phenotype (PFP). Mixed models were fit to examine the association between OI, OS, FI, and PFP, while adjusting for demographic and clinical covariates. Results Participants in the most-frail PFP category had lower OI and OS scores (OI: 3.88 vs 4.19, p = .016; OS: 3.15 vs 3.47, p = .031), whereas participants in the most-frail FI category exhibited lower OI scores but not OS scores when compared to nonfrail participants (OI: 3.72 vs 4.27, p = .014; OS: 3.19 vs 3.43, p = .476). Adjusted mixed models showed that a point increase in OI was associated with a lower PFP score (β = −0.107, p = .006) and FI score (β = −0.009, p = .010). A point increase in OS was associated with a lower PFP score (β = −0.058, p = .016) but not FI score (β = −0.004, p = .064). Conclusion Both OS and OI, predominantly peripheral and central measures of olfaction, respectively, are associated with frailty implicating olfaction as a potential biomarker and risk factor for frailty.

Background As rhinology fellowship positions outpace the availability of academic rhinology jobs, it is increasingly important to identify characteristics that are associated with academic placement after fellowship completion. In this study, we evaluated the association of academic characteristics during training with current job placement and posttraining scholarly impact. Methods Previous rhinology fellows were identified using publicly available data. Bibliometric indices, training institutions, graduate degrees, and job placement data were used in bivariate and multivariable regression analyses to assess for association with predictors and academic trajectory. Results Data from 265 rhinologists, all graduating between 1991 and 2020, were included. Most surgeons (n = 185, 70%) held an academic position and 80 (30%) surgeons worked in a nonacademic setting; 93.2% had a Doctor of Medicine (MD) degree and 80.3% were male. Multivariable logistic regression indicated that a designation of MD, compared with Doctor of Osteopathic Medicine (DO; odds ratio [OR], 5.93; 95% confidence interval [CI], 1.97-21.9), number of publications during fellowship (OR, 1.19; 95% CI, 1.02-1.41), and h-index during training (OR, 1.25; 95% CI, 1.07-1.49]) were independently predictive of academic job placement. Meanwhile, number of primary authorships during fellowship (β = 1.47; 95% CI, 1.07-1.88]), h-index during training (β = 0.48; 95% CI, 0.25-0.71), and PhD (β = 4.16; 95% CI, 1.57-6.76) were associated with posttraining h-index. Medical school ranking; graduate degrees, including Master of Science (MS), Master of Business Administration (MBA), and Master of Public Health (MPH); and research metrics before residency were not associated with either academic placement or posttraining h-index. Conclusion The predictors of academic job placement in rhinology are unclear, but h-index during training, and research productivity during fellowship may serve as indicators of an academic career.

Background The management of paranasal sinus and nasal cavity malignancies has evolved significantly with the development of advanced endoscopic techniques and improvements in adjuvant therapy. We sought to characterize both disease-specific survival (DSS) and 5-year conditional disease-specific survival (CDSS, the change in life expectancy with increasing survivorship) for sinus malignancies diagnosed before and after the year 2000. Methods Patients diagnosed with sinus and nasal cavity cancer between 1973-2015 were extracted from the Surveillance, Epidemiology, End Results (SEER) registry. Kaplan-Meier analysis for DSS was stratified by year of diagnosis before and after 2000. Cox-proportional hazards models of DSS controlling for stage, age, and year of diagnosis were generated. CDSS was calculated using Cox-regression models stratified by stage. Results We analyzed 10,535 patients. Diagnosis after the year 2000 was independently associated with improved DSS (HR:0.81, 95% CI: 0.75-0.87, P Conclusion For paranasal sinus and nasal cavity malignancies, year of diagnosis independently influences both DSS and CDSS. Improved survival is likely due to advances in both surgical and adjuvant treatments. To our knowledge, this study is the first to examine CDSS for these malignancies.

Background Evidence suggests chemosensory dysfunction (CSD) patients have altered diet, but population-level evidence assessing diet quality in CSD patients is lacking. Objective We examined the association between CSD and diet quality in a representative sample of United States adults. Methods This cross-sectional study included 2831 adults aged greater than 40 years from the 2013-2014 National Health and Nutrition Examination Survey who completed the taste/smell questionnaire and examination. Mean nutrient intake in subjects with self-reported olfactory/gustatory dysfunction (sOD/sGD) and measured olfactory/gustatory dysfunction (mOD/mGD) were compared to those without CSD using univariate Wilcoxon rank-sum tests. The Healthy Eating Index (HEI), a validated measure of diet quality, was calculated. The proportion of subjects with CSD with bottom-quartile HEI was compared to those without CSD using multivariate logistic regression, adjusting for demographic and socioeconomic covariates. Results The population-weighted prevalence of sOD, sGD, mOD, and mGD was 20.1%, 14.4%, 15.9% and 25.6%, respectively. Subjects with mOD had lower mean intake of total calories, total fat, protein, sodium, and potassium compared to normal subjects (1873.4 ± 49.6 vs 2010.2 ± 24.2 kcal, 72.3 ± 2.7 vs 78.6 ± 1.0 gm, 74.0 ± 2.5 vs 80.4 ± 0.6 gm, 3122 ± 97.2 vs 3353.2 ± 37.0 mg, 2509.8 ± 69.8 vs 2684.7 ± 26.1 mg, P Conclusions This population-level study suggests an association between poor diet quality and variation in dietary intake in patients with CSD, which warrants further investigation and suggests the possible need for nutritional counseling for CSD patients.

BACKGROUND As endoscopic endonasal skull base surgery (EESBS) for sellar pathology has become routine, there is increasing awareness of quality-of-life (QOL) outcomes related to this approach. Similarly, there is a growing interest in postoperative chemosensory function, with notable emphasis on olfaction and the corresponding psychosocial implications of olfactory dysfunction. Meanwhile, there has been minimal direct investigation into gustatory outcomes, and the association between these 2 chemosensory functions remains poorly understood. OBJECTIVE To investigate patient-reported chemosensory function and rhinologic-specific QOL following EESBS for routine sellar pathologies. METHODS Comprehensive clinical characteristics and sinonasal QOL assessments, measured using Anterior Skull Base Nasal Inventory-12 (ASK Nasal-12), were collected from 46 patients undergoing EESBS for sellar pathology. RESULTS Forty-six patients were included: 65.2% female, average age 52.8 yr (range: 27-89). The most common pathology was nonfunctioning pituitary adenoma (n = 28). Preoperative ASK Nasal-12 scores (mean = 0.81) demonstrated postoperative worsening at 2 wk (mean = 2.52, P

Patients with chemosensory dysfunction experience significant quality of life disruptions, including reduced enjoyment of eating. While chemosensory dysfunction has been associated with eating disorders, the relationship is poorly understood. This systematic review aims to characterize psychophysical gustation and olfaction in patients with eating disorders. Systematic review of investigations assessing psychophysical chemosensory function in patients with organic eating disorders. 26 studies were included. Five studies assessed both chemosenses, while 12 and 9 assessed exclusively gustation or olfaction, respectively. In total, 779 patients were included [72.4% anorexia nervosa (AN), 26.7% bulimia nervosa (BN), 0.8% combined AN/BN]. Patients with eating disorders experienced rates of hypogeusia up to 87% in AN and 84.6% in BN. There was evidence for alterations in psychophysical olfaction, but orientation of trends were less clear. Chemosensory dysfunction was more evident in AN patients. Treatment correlated with improved chemosensory function. Despite heterogeneity in study methodology and results, this review demonstrates that patients with eating disorders experience some degree of chemosensory dysfunction, particularly in gustation. This symptomatology overlaps with those experienced by patients with other causes of chemosensory impairment. These findings suggest potential broad psychosocial, dietary, and mental health implications in patient populations experiencing chemosensory dysfunction. Level II.

Because of involvement of the optic apparatus, craniopharyngiomas frequently present with visual deterioration. Although visual improvement is a primary goal of surgical intervention, prediction models are lacking.We retrospectively reviewed all patients undergoing craniopharyngioma surgery at a single institution (2014-2019). Preoperative, intraoperative, and postoperative variables of interest were collected. Visual acuity and visual fields (VFs) were standardized into Visual Impairment Scores (VISs), defined by the German Ophthalmological Society. VIS ranged from 0 (normal vision) to 100 (complete bilateral blindness). Visual improvement/deterioration was defined as a postsurgical decrease/increase of ≥5 VIS points, respectively.Complete ophthalmologic assessments were available for 61 operations, corresponding to 41 patients (age, 4-73 years). Vision improved after 28 operations (46%), remained stable after 27 (44%), and deteriorated after 6 (10%). In bivariate analysis, significant predictors of visual improvement included worse preoperative VIS (odds ratio [OR], 1.058; P0.001), worse preoperative VF mean deviation (OR, 1.107; P = 0.032), preoperative vision deficits presenting for longer than 1 month (OR, 6.050; P = 0.010), radiographic involvement of the anterior cerebral arteries (OR, 3.555; P = 0.019), and gross total resection (OR, 4.529; P = 0.022). The translaminar surgical approach was associated with visual deterioration (OR, 6.857; P = 0.035). In multivariate analysis, worse preoperative VIS remained significantly associated with postoperative visual improvement (OR, 1.060; P = 0.011). Simple linear correlation (RPatients with reduced preoperative vision, specific radiographic vascular involvement, and gross total resection showed increased odds of visual improvement, whereas the translaminar approach was associated with visual deterioration. Such characteristics may facilitate patient-surgeon counseling and surgical decision making.

SARS-CoV-2 infection of the upper airway and the subsequent immune response are early, critical factors in COVID-19 pathogenesis. By studying infection of human biopsies in vitro and in a hamster model in vivo, we demonstrated a transition in tropism from olfactory to respiratory epithelium as the virus evolved. Analyzing each variants revealed that SARS-CoV-2 WA1 or Delta infects a proportion of olfactory neurons in addition to the primary target sustentacular cells. The Delta variant possesses broader cellular invasion capacity into the submucosa, while Omicron displays longer retention in the sinonasal epithelium. The olfactory neuronal infection by WA1 and the subsequent olfactory bulb transport via axon is more pronounced in younger hosts. In addition, the observed viral clearance delay and phagocytic dysfunction in aged olfactory mucosa is accompanied by a decline of phagocytosis related genes. Furthermore, robust basal stem cell activation contributes to neuroepithelial regeneration and restores ACE2 expression post-infection. Together, our study characterized the nasal tropism of SARS-CoV-2 strains, immune clearance, and regeneration post infection. The shifting characteristics of viral infection at the airway portal provides insight into the variability of COVID-19 clinical features and may suggest differing strategies for early local intervention.

BACKGROUND Rhinologic disease can be responsible for systemic symptoms affecting mood, cognition, and sleep. It is unclear whether sleep disturbance in specific rhinologic disorders (chronic rhinosinusitis [CRS], rhinitis, and nasal septal deviation [NSD]) is an obstructive phenomenon or due to other mechanisms. In this review we examine the impact of CRS, rhinitis, and NSD on objective and subjective sleep outcome metrics and draw comparisons to normal controls and patients with known obstructive sleep apnea (OSA). METHODS A systematic review of 4 databases (PubMed, Scopus, Cochrane Library, and Web of Science) was performed. Studies reporting on objective (apnea-hypopnea index [AHI], respiratory disturbance index [RDI], oxygen nadir) and subjective (Epworth Sleepiness Scale [EpSS], Pittsburgh Sleep Quality Index [PSQI], Fatigue Severity Scale [FSS]) sleep parameters and disease-specific patient-reported outcome measures (PROMs; 22-item Sino-Nasal Outcome Test [SNOT-22], Rhinoconjunctivitis Quality of Life Questionnaire [RQLQ], Nasal Obstruction Symptom Evaluation [NOSE]) were included. RESULTS The database search yielded 1414 unique articles, of which 103 were included for analysis. Baseline PROMs were at the high end of normal to abnormal for all 3 conditions: EpSS: CRS (9.8 ± 4.0), rhinitis (9.7 ± 4.3), and NSD (8.9 ± 4.6); and PSQI: CRS (11.0 ± 4.5), rhinitis (6.1 ± 3.7), and NSD (8.6 ± 3.5). Objective measures demonstrated a mild to moderate OSA in the studied diseases: AHI: CRS (10.4 ± 11.5), rhinitis (8.6 ± 8.8), and NSD (13.0 ± 6.9). There were significant differences when compared with reported norms in all measured outcomes (p < 0.001). CONCLUSION Sleep quality is impacted by rhinologic (CRS, rhinitis, NSD) disease. There is likely a mild obstructive component contributing to poor sleep, but other contributing factors may be involved.

BACKGROUND Olfaction and gustation are associated with age-related decline. Deficits in these chemosenses have been associated with significant comorbidities. Meanwhile, frailty, defined as a reduced physiological reserve, is well correlated with mortality and worse health outcomes. We sought to analyze a nationally representative patient population to determine the association between chemosensory dysfunction and frailty. METHODS Cross-sectional analysis of U.S. National Health and Nutrition Examination Survey (NHANES) 2013-2014 was performed, using multivariate logistic regression to examine the association between chemosensory dysfunction and frailty in adults aged ≥40 years (n = 3547). Self-reported olfactory dysfunction (sOD) and gustatory dysfunction (sGD), and measured olfactory dysfunction (mOD) and gustatory dysfunction (mGD) were assessed for all participants. Frailty was operationalized using a 39-item frailty index (FI) and stratified into 4 groups using validated cutoffs. RESULTS Participants with sOD and mOD had significantly higher mean FI scores (sOD: 0.18 vs 0.13, p < 0.001; mOD: 0.20 vs 0.14, p < 0.001), whereas subjects with sGD, but not mGD, had higher mean FI scores (sGD: 0.21 vs 0.13, p < 0.001; mGD: 0.14 vs 0.14, p = 0.953). Multivariate logistic regression demonstrated frail participants had significantly greater odds of sGD (odds ratio [OR] 4.11; 95% confidence interval [CI], 3.46 to 4.88), sOD (OR 2.35; 95% CI, 1.98 to 2.78), and mOD (OR 1.58; 95% CI, 1.22 to 2.05), but not mGD (OR 1.21; 95% CI, 0.91 to 1.61). This association was strongest in the frailest group. CONCLUSION Self-reported chemosensory dysfunction and mOD are independently associated with measures of frailty, suggesting a novel method to assess or predict frailty.

Background Olfactory dysfunction (OD) has been reported to impact social interactions. However, the relationship between OD and loneliness has received little attention. The purpose of this study was to determine the association between OD and loneliness, controlling for patient factors. Methods Subjects without otolaryngic complaints were enrolled and olfactory function was assessed using: Sniffin’ Sticks test to measure threshold, discrimination and identification (TDI), Questionnaire of Olfactory Disorders Negative Statements (QOD-NS) and 9 – item Olfactory-Visual Analogue Scale (VAS). Loneliness was assessed using the De Jong Gierveld (DJG) and University of California Los Angeles (UCLA) loneliness scales. Bivariate analysis was performed followed by regression analysis, controlling for confounders. Results In total, 221 subjects were included with a mean age of 50.5 years (range 20 to 93), 133 (60.2%) females and 161 (72.9%) white. Mean TDI score was 29.3 (7.0) and 49.5% of the cohort was dysosmic. Using DJG, 36.4% of the cohort were classified as lonely, whereas 35.0% were lonely using UCLA. Olfactory measures were significantly associated with DJG, including TDI (β = −0.03, p = 0.050), olfactory discrimination (β = −0.111, p = 0.005), QOD-NS (β = 0.058, p Conclusions In this community-based sample of older adults, both OD and loneliness were common. Those subjects with worse olfactory function were more likely to report loneliness. Further research is necessary to establish causality, as well as explore the role of depression.

Background Viral respiratory tract infections are associated with a significant burden of disease and represent one of the leading causes of mortality worldwide. The current Coronavirus Disease 2019 (COVID-19) pandemic highlights the devastating toll that respiratory viruses have on humanity and the desperate need to understand the biological characteristics that define them in order to develop efficacious treatments and vaccines. To date, Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has infected nearly 600 times more people and resulted in 200 times more deaths relative to Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV) and Middle Eastern Respiratory Syndrome Coronavirus (MERS-CoV) combined. Objective Through this review, we aim to summarize the key characteristics of respiratory viruses that hold global significance, with a focus on SARS-CoV-2. Our goal is to disseminate our current knowledge of these infectious agents to otolaryngologists, in particular rhinologists, practicing in the COVID-19 era. Methods The general and clinical characteristics of selected respiratory viruses along with available viral treatments and vaccines are reviewed. Results There has been significant progress in our understanding of the epidemiology and pathogenesis of various respiratory viruses. However, despite the advancement in knowledge, efficacious vaccines and antiviral treatments remain elusive for most respiratory viruses. The dire need for these scientific discoveries is highlighted by the recent COVID-19 pandemic, which has prompted investigators worldwide to conduct clinical trials at an accelerated timeline in an effort to reduce the morbidity and mortality associated with SARS-CoV-2 infection. Rhinologists will continue to remain on the front-lines of pandemics associated with respiratory viruses. Conclusion In light of these unprecedented times, the need to understand the nuances of these viral respiratory pathogens, especially SARS-CoV-2, cannot be overemphasized. This knowledge base is of particular importance to otolaryngologists, whose expertise in the upper airway coincides with the anatomic tropism of these infectious agents.

OBJECTIVES Patients with chronic rhinosinusitis (CRS) often describe alterations in sense of taste. These complaints have historically been attributed to olfactory dysfunction; however, there is evidence of direct, objective, gustatory disturbances in the setting of CRS that are not thoroughly characterized. This study sought to investigate and summarize gustatory dysfunction experienced by patients with CRS. METHODS PubMed, EMBASE, Cochrane Library, Web of Science, and Scopus databases were reviewed following PRISMA guidelines. English language, original studies investigating objective taste in adult patients with CRS were included. A meta-analysis with inverse variance, random-effects model was performed. RESULTS Of 2750 studies screened, 11 articles with 471 unique patients were included. Patients with CRS exhibit worse gustatory function compared to healthy controls (standardized mean difference 0.94 [95% CI, 0.44-1.45]). Hypogeusia was identified in 32/95 (33.7%) patients from three studies that used methods with a validated definition of hypogeusia. Older age, male gender, and smoking history were associated with taste dysfunction, while objective gustatory and olfactory dysfunction were not correlated. Subjective taste and quality of life measures were also not associated with objective taste. The impact of sinus surgery on objective taste is unclear. CONCLUSION Approximately 34% of patients with CRS experience hypogeusia. Neither olfactory function nor subjective taste were associated with objective gustatory function. Given the substantial prevalence of taste dysfunction patients with CRS, there is significant potential for growth in understanding of pathogenesis, impact on quality of life, and potential treatment strategies of taste impairment in the CRS patient population. LEVEL OF EVIDENCE 1 Laryngoscope, 131:482-489, 2021.

Background Allergic fungal rhinosinusitis (AFRS) is disproportionately identified in patients of low socioeconomic status living in warm, humid climates, and is thought to occur in response to environmental fungal species. Objective We hypothesized that micro-geographic differences in fungal exposure contribute to the pathogenesis of AFRS, and compared home fungal exposure of patients with AFRS to normative data and controls. Methods Comprehensive prospective enrollment and data capture was completed in 70 patients. Patients with AFRS were compared to a control population with chronic rhinosinusitis with nasal polyposis (CRSwNP) and comorbid atopy. Comprehensive demographics, 22-item sino-nasal outcomes test (SNOT-22) questionnaires, and endoscopy scores were compiled. Using a test strip collection system, a home fungal assessment was completed for each patient, along with detailed questions related to home condition. Results Patients with AFRS were more likely to be younger (pConclusion This study failed to detect differences in total home fungal exposure levels between those with AFRS and atopic CRSwNP, despite differences in socioeconomic status. This suggests that absolute fungal levels may not be the primary driver in development of AFRS, or that the fungal detection strategies utilized were not representative of patients’ overall fungal exposure.

The treatment paradigm for the management of chronic rhinosinusitis with nasal polyposis (CRSwNP) is currently undergoing a rapid evolution with the development of monoclonal antibody therapies targeted at type 2 inflammatory pathways. The use of these biologic therapies in asthmatic patients, and more recently, patients with CRSwNP has produced promising results, especially for patients with severe disease. Many questions regarding the appropriate timing of these medications, whether or not these new treatment strategies should be used as a monotherapy or in conjunction with traditional therapies such as sinus surgery, the role of appropriate phenotyping, and identification of biomarkers, remain unanswered. We herein present a case of a patient with severe eosinophilic asthma and comorbid CRSwNP who failed to achieve control of his respiratory symptomology and ultimately progressed to sinus surgery despite treatment with an anti-interleukin 5 monoclonal antibody therapy (mepolizumab). Consideration is given to the mechanistic underpinnings of the reported patient's failure. This case highlights the need for further understanding of the optimal usage of these novel therapeutics in the management of CRSwNP and in the need to better understand the pathophysiology of CRSwNP.

Olfactory dysfunction (OD) is one of the cardinal symptoms of chronic rhinosinusitis (CRS), and its prevalence ranges from 60% to 80% in patients with CRS. It is much more common in CRS with nasal polyposis patients compared to CRS without nasal polyposis. Decreased olfactory function is associated with significant decreases in patient-reported quality of life (QOL), and notably, depression and the enjoyment of food. Objective measures can help detail the degree of OD, whereas subjective measures can help to determine in the impact on patient. There is variable treatment response to OD with both medical and surgical therapies.

Endoscopic endonasal skull base surgery (EESBS) has many advantages compared with traditional approaches. Recently, there is an increasing focus on patient-centered, quality of life (QOL), and approach-specific outcomes. This review seeks to illuminate our current understanding and knowledge gaps in EESBS-specific QOL outcomes. In an effort to capture the most relevant QOL implications for patients undergoing EESBS, three comprehensive, validated, QOL instruments have been created. These instruments are often supplemented by sinonasal-specific outcome measures, given the potentially significant sinonasal repercussions incurred with the use of the endonasal corridor. To date, most EESBS QOL investigations include patients with sellar-based pathology, though series with patients undergoing more extensive approaches are emerging. Generally, patients experience transient postoperative worsening of skull base– and sinonasal-specific QOL. Larger series, with validated QOL outcome measures, are needed to better understand patient outcomes and the morbidities of EESBS, especially those that relate to olfaction and surgery beyond the sella.

Recently, in-office posterior nasal nerve ablation (PNA) devices have offered a new tool to treat refractory chronic rhinitis, but their cost-effectiveness relative to traditional interventions such as vidian neurectomy (VN) and posterior nasal neurectomy (PNN) remains unexplored.To compare the cost-effectiveness of these interventions in patients with refractory chronic rhinitis.A decision tree with embedded Markov models was created to compare the cost-effectiveness of PNN, VN, and PNA, measured in quality-adjusted life years (QALYs) over a 30-year time horizon with a $100,000/QALY willingness-to-pay threshold. One- and two-way sensitivity analyses were completed.Sensitivity analysis found that in-office PNA became cost-effective compared to VN when patients undergoing PNA were less than 20 % more likely than VN to have symptoms recur; this value was assumed to be twice as likely in the base case. In the base case, however, VN and in-office PNA were more effective and less expensive than PNN, while VN was cost-effective when compared to in-office PNA (incremental cost-effectiveness ratio $11,616.24/QALY). Other assumptions were not found to considerably impact incremental cost-effectiveness.Although highly limited by currently available data, PNA may be cost-effective compared to VN as long-term outcomes on the durability of its effects emerge. These data should not be used by payers considering coverage or utilization since long-term data is still nascent. However, that as new technologies emerge for rhinitis, it will be important to monitor longer-term outcomes to identify high value care, but based on limited data PNA devices may meet this standard.

Background Chronic rhinosinusitis (CRS) presents with broad and systemic manifestations, including impaired sleep; however, the impact of CRS treatments upon sleep is unknown. Objective To establish the effect of medical or surgical CRS treatment on subjective and objective sleep metrics for patients not previously diagnosed with sleep apnea. Methods Review of PubMed, Scopus, Web of Science, and the Cochrane Library was performed from the databases’ date of inception through August 13, 2020, for studies evaluating the effect of CRS treatment on sleep quality. All studies reporting on subjective and objective sleep parameters for patients with CRS, with completed pre- and posttreatment data were included. Studies composed of patients with diagnosed sleep apnea were excluded. Results Sixteen unique studies reporting data on a total of 1770 patients (mean age, 50.6 ± 15.6 (n = 1675) years) following treatment for CRS were included. Patient-reported outcome measures, Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, and Fatigue Severity Scale, demonstrated mean posttreatment differences of −2.8 (95% CI: −4.9 to −0.7), −2.4 (95% CI: −3.7 to −1.2), and −1.2 (95% CI: −1.6 to −0.7), respectively. The SNOT-22 and its sleep domain demonstrated a mean posttreatment difference of −23.5 (95% CI: −31.7 to −15.3) and −5.4 (95% CI: −6.8 to −4.0), respectively. EpSS, FSS and SNOT-22 exceeded their respective reported MCID values. Objective findings did not significantly change with treatment; mean difference: AHI: 0.7 (95% CI: −1.5 to 2.9), oxygen nadir: 0.3 (95% CI: −0.4 to 0.9). Conclusions Treatment of CRS may lead to clinically meaningful reduction in disease burden and improvements in both overall sleep quality and patient-reported fatigue. Despite clinically meaningful quality of life improvements, objective sleep parameters did not demonstrate corresponding posttreatment improvements.

BACKGROUND: Bitter and sweet taste receptors (T2Rs and T1Rs), respectively, are involved in the innate immune response of the sinonasal cavity and associated with chronic rhinosinusitis (CRS). Growing evidence suggests extraoral TRs as relevant biomarkers, but the current understanding is incomplete. This systematic review synthesizes current evidence of extraoral taste receptors in CRS. METHODS: PubMed, Embase, Cochrane, Web of Science, and Scopus were reviewed in accordance with Preferred Reporting Items for Systemic Reviews and Meta-Analyses guidelines and included studies of genotypic and phenotypic T2R/T1R status in CRS patients. RESULTS: Twenty-two studies with 3845 patients were included. Seventeen studies evaluated genotype and 10 evaluated taste phenotypes. Four of 6 studies examining the haplotype distribution of the T2R, TAS2R38, demonstrated increased AVI/AVI haplotype (“nontaster”) frequency in CRS. Meanwhile, 2 studies demonstrated decreased bitter sensitivity in CRS with nasal polyposis (CRSwNP), whereas 3 other studies reported decreased bitter sensitivity only in CRS without nasal polyposis (CRSsNP). Findings regarding sweet sensitivity were mixed. Three studies with cystic fibrosis patients (n = 1393) were included. Studies investigating the association between clinical outcomes and TAS2R38 alleles were limited, but the nonfunctional combination of AVI/AVI was associated with increased utilization of sinus surgery and, in CRSsNP patients, with poorer improvement of symptoms postoperatively. CONCLUSION: Both genotypic and phenotypic assessments of T2Rs suggest a potential association with CRS, particularly CRSsNP. However, limited evidence and mixed conclusions cloud the role of T2Rs in CRS. Future investigations should aim to increase diverse populations, broaden institutional diversity, examine T1Rs, and utilize uniform assessments.

Meningiomas of the tuberculum sellae (TS) and planum sphenoidale (PS) are challenging to treat surgically. Transcranial approaches (TCAs) were the mainstay before endoscopic endonasal approaches (EEA) were developed, however the efficacy and safety of EEA approaches relative to TCA approaches remains unclear.The authors conducted a PRISMA-compliant systematic review of existing literature detailing the outcomes of both approaches. PubMed, Embase, Cochrane Library, and Clinicaltrials.gov were searched. Studies were included if they analyzed TS and/or PS meningiomas, included ≥ 5 patients, and reported at least one outcome of interest.Overall, 44 retrospective studies met inclusion criteria, the majority being from single centers, between 2004 and 2020. In studies directly comparing postoperative outcomes among TCA and EEA approaches, EEA had significantly higher odds of visual improvement (OR = 3.24, p = 0.0053) and significantly higher odds of CSF leak (OR = 3.71, p = 0.0098) relative to TCA. Further, there were no significant differences between visual worsening (p = 0.17), complications (p = 0.51), and GTR rates (p = 0.30) for the two approaches. Meta-analysis demonstrated no significant association between nasoseptal flap (NSF) use and postoperative outcomes among EEA patients. There was also no significant association between study publication year and postoperative EEA outcomes.The present study demonstrates that EEA offers a viable alternative to TCA in the treatment of suprasellar meningiomas. In particular, EEA shows promise for superior visual outcomes, though postoperative CSF leaks are an important consideration among patients undergoing this approach.

Introduction Endoscopic endonasal approaches (EEAs) are increasingly utilized for intracranial pathology. As opposed to sinonasal tumors, the nasal cavity is being used as a corridor to access these intracranial tumors but is not the site of primary surgical intent. Accordingly, there has been recent interest in preserving intranasal structures not directly involved by tumor and improving postoperative sinonasal quality of life (QOL). Objectives The aim of the study is to highlight recent advances in EEA techniques focused on improving sinonasal QOL including turbinate preservation, reducing the morbidity of reconstructive techniques, and the development of alternative minimally invasive EEA corridors. Methods The method of the study involves contemporary literature review and summary of implications for clinical practice. Results Nasoseptal flap (NSF) harvest is associated with significant morbidity including septal perforation, prolonged nasal crusting, and external nasal deformities. Various grafting and local rotational flaps have demonstrated the ability to significantly limit donor site morbidity. Free mucosal grafts have re-emerged as a reliable reconstructive option for sellar defects with an excellent sinonasal morbidity profile. Middle turbinate preservation is achievable in most EEA cases and has not been shown to cause postoperative obstructive sinusitis. Recently developed minimally invasive EEA techniques such as the superior ethmoidal approach have been described to better preserve intranasal structures while allowing intracranial access to resect skull base tumors and have shown promising sinonasal QOL results. Conclusion This contemporary review discusses balancing effective skull base reconstructive techniques with associated morbidity, the role of turbinate preservation in EEA, and the development of unique EEA techniques that allow for increased nasal structure preservation.

Our ability to smell and taste is dictated by 3 chemosensory systems with distinct physiologic mechanisms - olfaction, gustation, and chemesthesis. Although often overlooked, dysfunction of these special senses may have broad implications on multiple facets of patients' lives -including safety, nutritional status, quality of life, mental health, and even cognitive function. As "loss of smell or taste" emerged as a common symptom of coronavirus disease 2019 (COVID-19), the importance of intact chemosensory function has been thrust into the spotlight. Despite the growing recognition of chemosensory dysfunction, this already highly prevalent condition will increasingly impact a larger and more diverse population, highlighting the need for improved awareness and care of these patients.Comtemporary review of chemosensory function and assessments.Although patient-reported chemosensory function measures highlight the ease of screening of chemosensory dysfunction, self-reported measures underestimate both the prevalence and degree of chemosensory dysfunction and do not adequately distinguish between olfaction, gustation, and chemesthesis. Meanwhile, psychophysical assessment tools provide opportunities for more accurate, thorough assessment of the chemosenses when appropriate. Primary care providers are uniquely situated to identify patients burdened by chemosensory dysfunction and raise patient and provider awareness about the importance of chemosensory dysfunction. Identification of chemosensory dysfunction, particularly olfactory dysfunction, may raise suspicion for many underlying medical conditions, including early detection of neurodegenerative conditions. Furthermore, identification and awareness of patients with chemosensory dysfunction may help primary care providers to identify those who may benefit from additional therapeutic and safety interventions, or consultations with specialists for more detailed evaluations and management.