Objectives/Hypothesis The purpose of this study was to investigate the association of demographic factors, tumor stage, and treatment modalities for overall survival in patients with sinonasal mucosal melanoma (SNMM). Study Design Retrospective database review. Methods The National Cancer Database was queried for patients of all ages with SNMM between 2004 and 2015. Univariate Kaplan‐Meier and multivariate Cox regression analyses were performed to evaluate the association of suspected prognostic factors with overall survival. Results A total of 1,874 patients with SNMM were included in the analysis. The 5‐year overall survival was 24%. Prognostic factors associated with decreased survival include advanced age (hazard ratio [HR]: 1.02, 95% confidence interval [CI]: 1.01‐1.03), T4 disease (HR: 1.44, 95% CI: 1.09‐1.89), and presence of distant metastases (HR: 3.22. 95% CI: 2.06‐5.04). Improved survival was associated with surgical resection only when margins were negative (HR: 0.44; 95% CI: 0.30‐0.65). In patients with metastatic disease, administration of immunotherapy (HR: 0.14; 95% CI: 0.04‐0.49) was associated with improved survival. Surgical approach, radiotherapy, and chemotherapy were nonsignificant predictors of survival. Conclusions This investigation is the largest to date to analyze the association of treatment modalities with overall survival in SNMM. Surgery remains the mainstay of treatment in patients with SNMM. However, administration of immunotherapy may confer survival benefit to patients with metastatic disease. Level of Evidence NA Laryngoscope, 130:275–282, 2020

Objectives: Enhanced recovery after surgery (ERAS) protocols were first developed in colorectal surgery and sought to standardize patient care. There have been several studies in the head and neck surgical literature looking at outcomes after ERAS protocol, but no studies focusing on narcotic use and length of stay. This study aimed to evaluate narcotic usage and length of stay, in addition to several other outcomes, following the implementation of an ERAS protocol.Methods: A head and neck-specific ERAS protocol was implemented at this tertiary care center beginning July 2017. A retrospective cohort study was performed comparing this cohort to that of a retrospective control group. Outcomes included mean morphine equivalent dose, mean pain score, and percentage of patients prescribed narcotics on discharge. Secondary outcomes included ICU and total length of stay.Results: The mean morphine equivalent dose (MED) administered within 72 hours postoperatively was significantly lower in the ERAS group (17.5 AE 46.0 mg vs. 82.7 AE 116.1 mg, P < .001). Average postoperative pain scores in the first 72 hours were lower in the ERAS group (2.6 AE 1.8 vs. 3.6 AE 1.9; P < .001). The average length of stay was shorter for ERAS patients (7.8 AE 4.8 vs. 9.7 AE 4.7 days, P = .008); however, there was no significant difference in ICU length of stay.Conclusion: Following implementation of an ERAS protocol, patients undergoing head and neck surgery had decreased narcotic use in the immediate postoperative period and at discharge, while also demonstrating improved postoperative analgesia.

Objectives To further characterize the epidemiology, prognostic disease‐specific factors, and treatment outcomes—including newly available chemotherapy data—for patients with sinonasal diffuse large B‐cell lymphoma (DLBCL). Methods The Surveillance, Epidemiology, and End Results registry was queried from 1973 to 2015 for patients with DLBCL of the nasal cavity and paranasal sinuses. Demographic and disease parameters were collected. Prognostic disease‐specific survival and overall survival factors were evaluated with univariate Kaplan‐Meier analysis. Significant variables were analyzed with multivariate Cox regression analysis. Results A total of 1,273 cases of DLBCL of the sinonasal tract were identified. Significant differences in age of diagnosis between men (65.3) and women (71.1) existed (P < .01). Most common primary sites of DLBCL were maxillary sinus (36.1%) and nasal cavity (34.5%), with nasal cavity more common among Asian/Pacific Islands (43.4%) and maxillary sinus more common for Caucasians (36.3%) and African Americans (42.1%). Overall survival was 70% at 2 years, 54% at 5 years, and 38% at 10 years. Disease‐specific survival was 81%, 73%, and 67%, respectively. Chemotherapy (hazard ratio [HR]: 0.551; P < .001) and radiation therapy (HR: 0.818; P = .012) were associated with improved prognosis, whereas higher Ann Arbor stage worsened prognosis (HR: 1.21; P < .001). Surgical intervention did not significantly impact survival. Conclusion This is the first study to include chemoradiation therapy in population‐based analysis of sinonasal DLBCL. Chemotherapy and radiation therapy use significantly improve survival in these patients, whereas Ann Arbor staging is significantly associated with poorer outcomes. The mainstay of treatment for DLBCL should remain combination chemoradiation. Level of Evidence NA Laryngoscope, 129:1259–1264, 2019

Objectives/Hypothesis Failure after sinus surgery is multifactorial, but often due to recurrence of inflammatory mucosal disease. Postoperative steroid requirements for controlling mucosal inflammation may provide insight into predicting which patients require more aggressive medical therapy to prevent disease relapse. Study Design Retrospective chart review. Methods A review was performed of patients who underwent functional endoscopic sinus surgery (FESS) for refractory chronic rhinosinusitis (CRS). Sino‐Nasal Outcome Test‐22 scores and cumulative prednisone dose (milligrams) requirements at 1, 3, and 6 months postoperatively were reviewed. A structured histopathology report of 11 variables was accessed to correlate histopathology with postoperative steroid requirements. Results One hundred one patients were reviewed including 42 CRS with nasal polyps and 59 CRS without nasal polyps patients. CRS patients with eosinophilia required greater cumulative steroids to control disease at 1‐, 3‐, and 6‐month postoperative intervals (P < .026, P < .007, P < .013, respectively) compared to patients without eosinophilia. Patients with tissue eosinophil aggregates required the highest cumulative steroids at 1‐, 3‐, and 6‐month postoperative intervals (P < .003, P < .001, P < .001, respectively). When removing patients with eosinophil aggregates from the eosinophilia group, no difference persisted between patients with eosinophilia and those without eosinophilia at all intervals (P = .664, P = .735, P = .800, respectively). No other histopathology variable correlated with postoperative steroid requirement. Conclusions Tissue eosinophil aggregates appear to be the largest driving factor for increased prednisone requirements after sinus surgery to control mucosal disease than mere presence of eosinophils. This key finding may identify patients at high risk for failure after sinus surgery and guide more proactive postoperative management. Level of Evidence 4 Laryngoscope, 129:794–799, 2019

Objectives/Hypothesis: The purpose of this study was to investigate survival differences between low-grade and high-grade sinonasal adenocarcinoma (SNAC) by examining demographics, tumor characteristics, and treatment modalities.Study Design: Retrospective database analysis. Methods: The National Cancer Database was queried for patients with SNAC between 2004 and 2015. Univariate and multivariate analyses were performed for all cases of SNAC. Subsequent analysis focused on low-grade (grade 1 and grade 2) and high-grade (grade 3 and grade 4) SNAC.Results: A total of 1,288 patients with SNAC were included in the main cohort and divided into low grade (n = 601) and high grade (n = 370). The 5-year overall survival for all patients, low-grade, and high-grade was 54%, 64%, and 38%, respectively. Prognostic factors associated with decreased survival for the main cohort include advanced age (hazard ratio [HR]: 1.04; 95% confidence interval [CI]: 1.03-1.06), Charlson-Deyo score (HR: 1.37; 95% CI: 1.05-1.78), grade 2 (HR: 2.21; 95% CI: 1.26-3.86], grade 3 (HR: 3.67; 95% CI: 2.09-6.45), and grade 4 (HR: 3.31; 95% CI: 1.38-7.91). Radiotherapy was associated with improved overall survival for high-grade SNAC (HR: 0.41; 95% CI: 0.24-0.70) but not for low-grade SNAC (HR: 1.05; 95% CI: 0.59-1.85).Conclusions: This investigation is the largest to date analyzing the association of treatment modalities with overall survival in SNAC. Surgery remains paramount to treatment, with radiotherapy offering additional survival benefit for high-grade SNAC. Administration of chemotherapy was not associated with improved survival.

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BackgroundChronic rhinosinusitis (CRS) is an inflammatory disease process characterized by different phenotypes and histopathology profiles. Race and access to care have been implicated in CRS disease severity. Structural histopathology reporting may aid in delineating the inflammatory burden responsible for this effect.MethodsA structured histopathology report of 14 variables was utilized to assess sinus tissue removed during functional endoscopic sinus surgery (FESS). Histopathology variables and 22‐item Sino‐Nasal Outcome Test (SNOT‐22) scores were compared by race (Black, White, Latino, and Asian) and insurance status (Medicare, Medicaid, and private insurance).ResultsA total of 201 CRS patients (124 White, 38 Black, 28 Latino, and 9 Asian) undergoing FESS were included. Black patients demonstrated increased SNOT‐22 scores (50.74 ± 20.32 vs 41.47 ± 22.75, p < 0.022) and number of eosinophils per high‐power field (>5/HPF) (60.5% vs 44.8%, p < 0.05). White patients demonstrated decreased eosinophil aggregates (22.6% vs 35.1%, p < 0.039) and eosinophils/HPF (<5/HPF) (42.7% vs 55.8%, p < 0.048). Medicaid patients showed increased SNOT‐22 score (55.50 ± 24.46 vs 41.39 ± 21.74, p < 0.003), polypoid disease (61.5% vs 42.3%, p < 0.05), subepithelial edema (80.8% vs 53.1%, p < 0.006), hyperplastic/papillary changes (23.1% vs 8.0%, p < 0.028), fibrosis (61.5% vs 38.5%, p < 0.036), eosinophil aggregates (46.2% vs 24.6%, p < 0.022), and eosinophils/HPF (>5/HPF) (65.4% vs 45.1%, p < 0.043). When controlling for insurance status, Black race was no longer associated with increased SNOT‐22 (p < 0.104) or eosinophils/HPF (>5/HPF) (p < 0.183).ConclusionBlack and Medicaid patients demonstrated more severe disease by histopathology and SNOT‐22 scores. These findings were no longer significant among Black patients after adjusting for insurance status, suggesting that the prevailing factor influencing worse disease may be access to care.

Background: Chronic rhinosinusitis (CRS) is an inflammatory disease process with several different phenotypes. Recent data has shown that CRS phenotypes maintain distinct nasal microbiota that may predict surgical outcomes. Nasal microbiota and structured histopathologic reporting have the potential to further differentiate subtypes and provide additional insight into the pathophysiology of CRS. Methods:Sinus swabs collected during functional endoscopic sinus surgery (FESS) were studied by polymerase chain reaction analysis of 16S ribosomal RNA. A structured histopathology report of 13 variables was utilized to analyze sinus tissue removed during FESS. Histopathology variables and relative abundance of nasal microbiota were compared among CRS patients. Results: A total of 51 CRS patients who underwent FESS were included. Relative abundance of the Firmicutes phylum in nasal microbiota of CRS patients was associated with presence of neutrophilic infiltrate (27.47 ± 44.75 vs 9.21 ± 11.84, p < 0.029), presence of mucosal ulceration (47.67 ± 45.52 vs 13.27 ± 26.48, p < 0.041), presence of squamous metaplasia (5562.70 ± 2715.66 vs 3563.73 ± 2580.84, p < 0.035), and absence of Charcot-Leyden crystals (5423.00 ± 3320.57 vs 679.94 ± 1653.66, p < 0.001).Relative abundance of the Bacteroidetes phylum in nasal microbiota of CRS patients was associated with increased severity of inflammatory degree (p < 0.004) and presence of mucosal ulceration (p < 0.004). Conclusion: Distinct histopathologic features of CRS are associated with relative abundance of nasal microbiota phyla, specifically Firmicutes and Bacteroidetes. These findings contribute to the growing body of literature on microbiota in sinonasal disease and may have important implications for understanding pathophysiologic mechanisms of CRS subtypes and disease management. C 2018 ARS-AAOA, LLC. How to Cite this Article: Kuhar HN, Tajudeen BA, Mahdavinia M, et al. Relative abundance of nasal microbiota in chronic rhinosinusitis by structured histopathology. Int Forum Allergy Rhinol. 2018;8:1430-1437.