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Analysis 2.2. Comparison 2 Intranasal steroids versus nasal saline (nebulised, small-volume), Outcome 2 Adverse events. Analysis 2.3. Comparison 2 Intranasal steroids versus nasal saline (nebulised, small-volume), Outcome 3 Endoscopy scoremeasured using modified Lund-Mackay (range unknown

ObjectivesTo explore patient views and perspectives of current management of chronic rhinosinusitis (CRS) in primary and secondary care.DesignSemistructured qualitative telephone interviews as part of the MACRO programme (Defining best Management for Adults with Chronic RhinOsinusitis).SettingPrimary care and secondary care ear, nose and throat outpatient clinics in the UK.ParticipantsTwenty-five patients consented to in-depth telephone interviews. Transcribed recordings were managed using NVivo software and analysed using inductive thematic analysis.ResultsCRS has a significant impact on patients’ quality of life, affecting their ability to work effectively, their social interactions and daily living. Patients seek help when symptoms become unmanageable, but can become frustrated with the primary care system with difficulties obtaining an appointment, and lack of continuity of care. Patients perceive that general practitioners can be dismissive of CRS symptoms, and patients often prioritise other concerns when they consult. Health system barriers and poor communication can result in delays in accessing appropriate treatment and referral. Adherence to intranasal steroids is a problem and patients are uncertain about correct technique. Nasal irrigation can be time-consuming and difficult for patients to use. Secondary care consultations can appear rushed, and patients would like specialists to take a more ‘holistic’ approach to their management. Surgery is often considered a temporary solution, appropriate when medical options have been explored.ConclusionsPatients are frustrated with the management of their CRS, and poor communication can result in delays in receiving appropriate treatment and timely referral. Patients seek better understanding of their condition and guidance to support treatments decisions in light of uncertainties around the different medical and surgical options. Better coordinated care between general practice and specialist settings and consistency of advice has the potential to increase patient satisfaction and improve outcomes.

Defective or immature antibody responses to pathogens in children may explain the increased susceptibility to acute otitis media (AOM) in otitis-prone children. In literature, data on immunology have been based on studies of small groups of severely otitis-prone children and have not been consistent. Humoral immune status was assessed in 365 children, 1-7 years old, with two or more documented episodes of AOM in the previous year. Children with 4 or more episodes in the preceding year were defined as otitis-prone. Serum immunoglobulin levels were determined by radial immunodiffusion. Immunoglobulin levels of otitis-prone children were compared with those of children who had experienced 2-3 AOM episodes per year. Children with recurrent episodes of AOM were found to have normal or increased serum IgA, IgM, IgG, and IgG1 levels compared with normal values for age, whereas the serum IgG2 levels were mostly in the lower normal range. Twenty-two percent of all children showed IgG2 levels lower than 2 SD below the age-specific mean. Interestingly, the otitis-prone group of children showed significantly lower median and mean levels for all immunoglobulins compared with those children with only 2-3 previous AOM episodes. Lower immunoglobulin levels in otitis-prone children suggest a generalized decreased antibody response in otitis-prone children. Based on the clinical observation that some children experience recurrent episodes of acute otitis media (AOM), the term "otitis-prone" was introduced by Howie (1). In general, the otitis-prone condition is defined as three or more episodes of AOM in 6 mo or four or more episodes in 12 mo; up to 5% of all children comply with this definition (2, 3).With respect to immunoglobulin serum levels, both normal as well as stimulated serum IgA, IgM, IgG, and IgG1 levels have been reported in otitis-prone children aged 2 mo or older (4, 5). Freijd et al. and Sørensen et al. reported lower levels of IgG2 in children with recurrent AOM compared with agematched controls (5, 6), but others did not confirm these observations (4, 7).With respect to antibody activity against the two main bacterial pathogens in AOM Streptococcus pneumoniae and nontypeable Haemophilus influenzae (NTHI), subnormal or absent antibody responses have been reported in otitis-prone children (8 -11), as well as decreased antibody responses upon immunization with Hib conjugate and rubella vaccine (12, 13).These findings may suggest decreased antibody responses upon both T cell-dependent as well as T cell independent antigens in otitis-prone children (14). Hitherto, immunologic evaluations have been performed only in small groups of otitis-prone children. The need to obtain more substantial data led us to analyze immunoglobulins in a large group of 365 children with varying susceptibility to acute otitis media. METHODSThis study was conducted in a general hospital (Spaarne Hospital Haarlem) and a tertiary care hospital (University Medical Center Utrecht), the Netherlands. The Medical Ethics Committees of both participa...

We have identified outcomes that both patients and their doctors consider should be included in reviews evaluating treatments of rhinosinusitis. We recommend that primary outcomes in future reviews focus on symptom-based outcomes. The ability to extract these data from relevant trials is dependent upon their inclusion in trials, and so it is important that building on this work a core outcome set for rhinosinusitis research is developed.

ObjectivesTo explore general practitioner (GP) and ears, nose and throat (ENT) specialist perspectives of current treatment strategies for chronic rhinosinusitis (CRS) and care pathways through primary and secondary care.DesignSemi-structured qualitative telephone interviews as part of the MACRO programme (Defining best Management for Adults with Chronic Rhinosinusitis)SettingPrimary care and secondary care ENT outpatient clinics in the UK.ParticipantsTwelve GPs and 9 ENT specialists consented to in-depth telephone interviews. Transcribed recordings were managed using NVivo software and analysed using inductive thematic analysis.Main outcome measuresHealthcare professional views of management options and care pathways for CRS.ResultsGPs describe themselves as confident in recognising CRS, with the exception of assessing nasal polyps. In contrast, specialists report common missed diagnoses (eg, allergy; chronic headache) when patients are referred to ENT clinics, and attribute this to the limited ENT training of GPs. Steroid nasal sprays provide the foundation of treatment in primary care, although local prescribing restrictions can affect treatment choice and poor adherence is perceived to be the causes of inadequate symptom control. Symptom severity, poor response to medical treatment and patient pressure drive referral, although there is uncertainty about optimal timing. Treatment decisions in secondary care are based on disease severity, polyp status, prior medical treatment and patient choice, but there is major uncertainty about the place of longer courses of antibiotics and the use of oral steroids. Surgery is regarded as an important treatment option for patients with severe symptoms or with nasal polyps, although timing of surgery remains unclear, and the uncertainty about net long-term benefits of surgery makes balancing of benefits and risks more difficult.ConclusionsClinicians are uncertain about best management of patients with CRS in both primary and secondary care and practice is varied. An integrated care pathway for CRS is needed to improve patient management and timely referral.

H. V. (2020). Antimicrobial mouthwashes (gargling) and nasal sprays administered to patients with suspected or confirmed COVID-19 infection to improve patient outcomes and to protect healthcare workers treating them.