DO NOT COPY. Smell disturbance is one of the most common complaints of. Objective olfactory outcomes after revision endoscopic sinus surgery

Transcription

1 Objective olfactory outcomes after revision endoscopic sinus surgery Chao-Yuan Hsu, M.D., 1 Ying-Piao Wang, M.D., 2 Ping-Hung Shen, M.D., 3 Erik Kent Weitzel, M.D., 4 Jen-Tsung Lai, M.D., 1 and Peter-John Wormald, M.D. 5 ABSTRACT Background: Patients who suffer from hyposmia and anosmia report a negative effect on their overall quality of life. Smell disturbance of patients with chronic rhinosinusitis (CRS) can improve after endoscopic sinus surgery (ESS). Although several studies have shown that 50 83% of patients may notice an improvement in olfactory function after ESS, the olfactory improvement after revision ESS (RESS), especially by objective measurements, is still lacking. Methods: Olfactory function was assessed by the traditional Chinese version of the University of Pennsylvania Smell Identification Test (UPSIT-TC) preoperatively and postoperatively, recorded as smell identification test (SIT) score. Olfactory outcomes from anosmia to hyposmia/normosmia, or from hyposmia to normosmia, were considered as improvement. Postoperative assessments were divided into two periods: period 1 (P1) is defined as 6 but 12 months postoperatively; period 2 (P2) is defined as 12 but 24 months postoperatively. Results: Thirty-two patients with smell disturbance preoperatively (period 0 [P0]) and confirmed by UPSIT-TC were enrolled into this study. Mean SIT score at P0 was 13.3; mean SIT score at P1 was 18.6; mean SIT score at P2 was The presence of nasal polyps blocking the olfactory cleft were associated with better olfaction improvements (p 0.05) as was the degree of mucosal swelling. The overall improvement rates were 44.8 and 47.8% at P1 and P2, respectively. Conclusion: RESS resulted in objective evidence of olfactory improvement in approximately one-half of our cohort over 16 months of follow-up and offers a treatment option for an otherwise poor prognosis condition. (Am J Rhinol Allergy 27, e96 e100, 2013; doi: /ajra ) Smell disturbance is one of the most common complaints of chronic rhinosinusitis (CRS) patients and causes a negative impact on overall quality of life. 1 5 Fortunately, olfactory loss due to CRS can be improved through either surgical or medical therapy. 2,6 8 Endoscopic sinus surgery (ESS) has been shown to improve the sense of smell in patients with loss of olfaction due to CRS. 1,9 14 Although ESS is very effective in the treatment of CRS, a group of patients continue to have significant loss of smell postoperatively (2.5 24%). 15,16 Revision ESS (RESS) has been described as a helpful intervention for the patient failing primary ESS, 16,17 but its effect on smell postoperatively is not well known. This study aims to determine the relationship between RESS and olfactory outcomes through longterm objective smell identification testing (SIT). MATERIALS AND METHODS Study Design Institutional Review Board (Kuang-Tien General Hospital) approval was obtained (KTGH IRB no ) and after informed consent, patients presenting for revision surgery for recurrent or recalcitrant CRS were enrolled. Patients were excluded from recruitment for preexisting subjective smell disturbance or age 18 years. Patients did not receive preoperative steroids and were instructed to not take From the 1 Department of Otolaryngology, Kuang-Tien General Hospital, Taichung, Taiwan, 2 Department of Otolaryngology Head and Neck Surgery, Mackay Memorial Hospital, Taipei, Taiwan, 3 Department of Otolaryngology, Kuang-Tien General Hospital, and Department of Biotechnology, Hung-Kuang University, Taichung, Taiwan, 4 Department of Otolaryngology, Wilford Hall Ambulatory Surgical Center, Lackland Air Force Base, Texas, and 5 Department of Surgery Otolaryngology, University of Adelaide, South Australia, Australia PJ Wormald has financial interest/arrangement with Medtronic Xomed for royalties received from design of surgical instruments. The remaining authors have no conflicts of interest to declare pertaining to this article Address correspondence to Ping-Hung Shen, M.D., Department of Otolaryngology, Kuang-Tien General Hospital, No.117, Shatian Road, Shalu District, Taichung City, 433 Taiwan; alternative: Department of Biotechnology, Hung-Kuang University, No. 1018, Section 6, Taiwan Boulevard, Shalu District, Taichung City, 433 Taiwan address: allentube211@gmail.com Copyright 2013, OceanSide Publications, Inc., U.S.A. anticoagulants for 7 days before the surgery. Postoperative assessments were divided into two periods: period 1 (P1) is defined as between 6 and 12 months postoperatively; period 2 (P2) is defined as between 12 and 24 months postoperatively. Standard Operative Technique and Postoperative Management All patients underwent full-house ESS 16,18,19 and controlled hypotensive anesthesia for better surgical field. 20 Special attention was paid to the olfactory cleft with polypoid tissue between the middle turbinate and septum debrided up to the level of olfactory epithelium. This area was then packed with a thin slice of Spongostan (Ferrosan A/S, Soborg, Denmark) to maintain patency. Postoperative management included a 6-week course of 1.0 g of clarithromycin antibiotic daily, nasal douching, and topical steroids at night after nasal douching. Oral steroids were not given unless the patient was noted to have massive polypoid changes during postoperative endoscopy. Objective Data Collection and Assessment All objective data were recorded by a single rhinologist (P.H.S.) at P1 and P2. Olfaction function was assessed by the traditional Chinese version of the University of Pennsylvania Smell Identification Test (UPSIT-TC; 40 odorants) preoperatively (period 0, [P0]) and postoperatively (P1 and P2), recorded as SIT score. Olfaction outcomes from anosmic to hyposmia/normosmia or from hyposmia to normosmia were considered as improvement. Normative data for UPSIT is shown in Table 1. Preoperative objective measurements include computed tomography (CT) score (Lund-MacKay score [LMS]) and postoperative endoscopic findings with two parameters: presence of mucosal swelling (MS) and mucopus (MP) rated from 0 to 3 (0 none, 1 mild, 2 moderate, and 3 severe). 16 Presence of nasal polyp and olfactory cleft obstruction were noted at the time of surgery as well as the presence of asthma and peripheral eosinophilia were all recorded to analyze their impact on postoperative olfaction outcomes. Peripheral eosinophilia was defined as 5% of peripheral blood leukocytes. Sinus ossification was defined as the presence of thickened bone relative to the contralateral subsite on CT scan. This finding was then confirmed intraoperatively by the presence of thick, highly vascular neo-osteogenesis. e96 July August 2013, Vol. 27, No. 4

2 Table 1 Normative data for UPSIT Anosmic Patients Statistical Analysis Microsomic/Hyposmic Patients Normosmic Patients Men Women UPSIT University of Pennsylvania Smell Identification Test. Table 2 Demographic and some clinical patient data at P0, P1, and P2 (cases listed only complete follow-up at P2, total: 23 patients) No. P0 P1 P2 LMS d(p2 P1) d(p2 P0) 1 12* 26# 32# * 15* 15* # * 33# 33# * 12* 8* * 15* 17* * 12* 28# * 19# 17* * * 29# 30# * 21# 26# * 28# 30# * 19# 19# * 14* 14* * 26# 30# * 7* 7* * 10* 9* * 9* 13* * 8* 7* * 12* 10* * 23# 26# * 12* 12* * 12* 13* *anosmic patients. #hyposmic patients. normosmic patients. SIT smell identification test; P0 SIT score preoperative period; P1 SIT score at period 1; P2 SIT score at period 2; d(p2 P1) SIT score differences between P2 and P1; d(p2 P0) SIT score differences between P2 and P0; LMS Lund-Mackay score. All data are presented as mean values SEM. Pearson s chi-square test and Fisher s exact test for dichotomous data, ordinal scales relationship using Spearman rank-order correlations, and olfaction outcomes at P1 and P2 were compared using Wilcoxon signed-rank test. The level of significance was set at p All analyses were performed using the Statistical Package for the Social Sciences, Version 12.0 software system (SPSS, Inc., Chicago, IL). RESULTS Thirty-two patients with smell disturbance confirmed by UPSIT-TC were enrolled into this study. Three patients were lost to follow-up at the P1 (n 29) visit and six were lost to subsequent follow-up (n 23). Mean follow-up time at P1 is 8.2 (6 11) and 15.9 at P2 (13 21). Some important patient data and smell improvements are illustrated in Table 2. Mean SIT score at P0 was (range, 8 29); mean SIT score at P1 was (range, 7 37); mean SIT score at P2 was (range, 7 36). The overall improvement is shown in Fig. 1. Table 3 Demographic and clinical data at P1 and P2 Variable P1 (n 29; M/F 20/9) Mean SEM (range) P2(n 23; M/F 14/9) Mean SEM (range) Age (yr) (20 77) (20 77) LMS (4 24) (4 24) N_PS (1 3) (1 3) F_U (6 11) (13 21) SIT_P (8 29) (8 29) SIT_P (7 37) N/A SIT_P2 N/A (7 36) d(p1 P0) ( 6 20) N/A d(p2 P0) N/A ( 2 20) SIT smell identification test; P1 period 1; P2 period 2; LMS Lund-Mackay CT score; N_PS no. of previous surgery; F_U follow-up time postoperatively(mo); SIT_P0: SIT score preoperatively; SIT_P1 SIT at P1; SIT_P2 SIT at P2; d(p1 p0) SIT improvements from P0 to P1; d(p2 P0) SIT improvements from P0 to P2. The other demographic features and olfaction outcomes were summarized in Table 3. Results at P1 Nasal polyps, MS, and age all had statistically significant impacts on the potential for olfactory recovery (Table 4). Correlation coefficients suggest that age had the lowest correlation for impact (MS, r and p 0.000; age, r and p 0.008). LMS, number of previous surgeries, MP, and gender all failed to show any correlation to olfactory outcomes. The overall improvement rate at P1 is 44.8% (13/29). Results at P2 After 12 months postoperatively, the presence of nasal polyp, MS, presence of sinus ossification, and age were associated significantly with olfactory improvements (Table 5). Gender, LMS, number of previous sinus surgeries, and MP continued to show no significant difference in terms of olfactory recovery. The overall improvement rate at P2 is 47.8% (11/23). Results between P1 and P2 When we look at interval changes from P1 to P2, two normosmic patients retained their smell function. In the hyposmic subgroup at P1 (n 9), one patient regressed to anosmia (UPSIT, 19 17), two patients remained stable in their SIT score, and six continued to improve (Figs. 1 and 2). If we look at the anosmic patients at P1 (SIT score 19; n 12), only one subsequently improved (this patient underwent modified Lothrop procedure, case 10). DISCUSSION Improvement of CRS-related olfactory dysfunction after ESS is variable and challenging to predict. 21 Several studies have shown that 50 83% of patients may notice an improvement in olfactory function after ESS, 1,22 25 although most of these studies suffer from lack of objective outcome measures relying on purely subjective responses. Yip et al. 1 found 57.4% (39/68) patients experienced subjective olfactory improvement after modified Lothrop procedure with 35.6 months of follow-up. Minovi et al. 26 also reported that the Draf III procedure produces an increase in olfactory function. Our recent study 16 found that 66.7% (10/ 15) of patients undergoing RESS experienced significant olfactory outcome improvements if they had a preoperative impairment in their sense of smell. Two additional articles 27,28 also report RESS-related improvements in subjective olfactory outcomes. This is the first study, to our knowledge, that uses objective outcome measures to evaluate the effect that RESS has on postoperative smell function. American Journal of Rhinology & Allergy e97

3 Table 4 Polyps Olfactory changes at P1 Improved Unimproved or Declined p Value Nasal polyp 0.047* Present 8 4 Not present 5 12 Olfactory cleft obstruction Present Not present 0 4 Sinus ossification 0.17 Present 4 9 Not present 9 7 Asthma Present 2 2 Not present Peripheral eosinophilia Present 3 2 Not present Smoking Present 6 6 Not present 7 10 Using Pearson s chi-square test and Fischer s exact test. *Statistically significant. P1 period 1. In the recent review by Rudmik et al. 21 it was suggested that there is a better chance of olfactory recovery in patients undergoing ESS for patients with CRS with nasal polyposis (CRSwNP) compared with CRS patients with hyposmia without nasal polyposis. Our study also supports this finding as seen in Tables 4 and 5. However, conflicting data do exist; Jiang et al. 29 concluded in his study that coexistence of nasal polyps or allergic rhinitis did not predict the possibility of olfactory improvement after functional ESS. The same group 30 studied patients with severe CRS and smell loss and concluded that ESS has little impact on recovery of the ability to smell. These findings were thought to reflect the severe nature of the initial olfactory deficit Table 5 Olfactory changes at P2 Figure 1. One hundred percent stacked bar highlights overall smell identification test (SIT) improvement proportionally. Improved Unimproved or Declined p Value Nasal polyp 0.022* Present 8 3 Not present 3 9 Olfactory cleft obstruction Present 11 8 Not present 0 4 Sinus ossification 0.009* Present 1 8 Not present 10 4 Asthma Present 2 2 Not present 9 10 Peripheral eosinophilia Present 3 1 Not present 8 11 Smoking Present 2 6 Not present 9 6 Using Pearson s chi-square test and Fischer s exact test. *Statistically significant. P2 period 2. and more extensive respiratory mucosal disease within the olfactory area in patients who continue to be anosmic despite optimal surgical management. Our overall improvement rate at P1 was 44.8% and at P2 was 47.8% (Fig. 1) is more consistent with the report by Rudmik et al. We believe this is explained through advantages offered by a highly aggressive surgery (full-house functional ESS or total sphenoethmoidectomy, Draf IIA, and wide maxillary antrostomy). The dramatic reduction in mucosal disease burden offered by this technique permits unimpeded topical access to the freshly debrided mucosa to prevent recurrent edema after RESS and long-term maintenance of this result. 16,18,19 e98 July August 2013, Vol. 27, No. 4

4 Figure 2. Smell identification test (SIT) score improvement from period 1 to period 2 (P1 to P2). Note, one patient had a declined score; two patients remained with the same score; the other six patients improved their scores. Aspirin-Exacerbated Respiratory Disease Katotomichelakis et al. 31 studied their CRSwNP patients and found olfactory function at the 6th postoperative month was significantly better in younger patients. The same author separately reported that aspirin-exacerbated respiratory disease (AERD) is an additional predictor of worse olfactory outcomes. 32 Our results also found a negative correlation between age and olfactory improvements. Our study included only one patient with AERD who did not show improvement (case17; Table 2). Mucosal Edema A multi-institutional, cross-sectional analysis of 367 patients performed by Litvack et al. in concluded that olfaction scores correlated well with endoscopy scores. Downey similarly showed that the presence of polypoid mucosa postoperatively will result in worse olfactory outcomes. 24 We found MS scores correlated significantly with olfactory outcomes: the more polypoid mucosa, the worse SIT scores. However, the presence of discharge (MP) did not correlate with postoperative SIT scores. Preoperative CT scores have been shown by Litvack 33 to positively correlate CT scores and SIT, but the study did not focus on revision cases. Our data failed to show any correlation between CT scores (LMS) and preoperative SIT scores (SIT-P0). 34 Conductive Defects The underlying pathophysiology for recurrent CRS-related olfactory dysfunction is complex and multifactorial, likely related to mechanical obstruction and neuroepithelial injury from chronic inflammation. 7,8,21 One study showed that polyps protruding from the olfactory cleft accounted for almost one-third of all of the lesions in nasal polyposis. 35 To date, several studies have been reported on the correlation between the severity of CT scores and/or the status of the olfactory cleft and the degree of olfactory dysfunction. Some researchers have suggested that the severity stage determined by CT was related to a poor outcome for olfactory function. 24,36 Other investigators have reported that the opacification of the olfactory cleft had a negative correlation with olfactory function scores in patients with CRS. 11,37 In our study we found that that 11 of 19 patients (57.9%) with olfactory cleft obstruction improved after surgery, and none of the 4 patients without olfactory cleft pathology improved (p 0.093; Table 5). Further examination of this relationship is needed. Osteitis (or Ossification) Georgalas et al. found that in patients with recalcitrant CRS who have undergone multiple surgeries in the past, the incidence of osteitis (new bone formation) can be as high as 64%. 38 Sinus neo-osteogenesis or osteitis was noted in our study in 44.9% before RESS (13/29). We found that there was a higher incidence of poor olfactory outcomes in P1 and P2 in this group. This might be interpreted as recalcitrant sinus disease with recurrent mucosal edema more likely associated with a recurrence of CRS. Considerations Currently, the literature suggests that there is a poor correlation between objective olfactory results and subjective patient improvement. Previous studies 39,40 have shown poor correlation between subjective and objective assessments of olfactory function, although Welge-Luessen et al. 41 did find a moderate correlation. In this study, we did find some anosmic patients reported huge improvements in their sense of smell after surgery, but the postoperative SIT scores were still within anosmic range (i.e, patients 7 and 9). Our results suggest subjective olfactory improvements are typically better than objective ones in this study. Weakness in the study design allowed for the introduction of two potential confounding factors. A 6-week course of macrolide is a standard postoperative medical course after sinus surgery at this research institution. The literature is replete with evidence that macrolides have anti-inflammatory properties on sinus mucosa Thus, our postoperative medical regimen may have introduced a nonsurgical cause of improvement in olfaction. However, because our outcome data were collected between 6 and 16 months postoperatively, we assume that any effect caused in the perioperative period by a medical regimen would not be a temporary effect at this delay. The second confounding effect is related to the potential for atopy to affect olfaction. As a stabilizing effect on this potential bias, patients were not offered or treated with immunotherapy and seasonal allergy is not obvious in Taiwan. The vast majority of allergens in Taiwan are house-dust mites. 45 Subgroup analysis of our cohort showed that at P1 5 of 29 patients tested were found to be atopic. Chi-square testing found no significant relationship between improvement in olfaction and atopy. Similarly, at P2, 4 of 23 patients tested were found to be atopic and, again, no statistical relationship was found between olfaction and atopy. Because the purpose of the study did not entail a American Journal of Rhinology & Allergy e99

5 detailed analysis of the potential for atopy to be a factor for intractable hyposmia after sinus surgery, the small numbers for this analysis may represent a type I error and would best be reevaluated with additional research. CONCLUSION This study aimed to assess olfactory changes after RESS using the UPSIT-TC as an objective measurement tool. Outcomes after RESS for patients with CRS are difficult to predict, and, among these, olfactory outcomes are particularly nebulous. We found that nearly one-half of patients with recalcitrant CRS regain their sense of smell after revision full-house ESS. Interestingly, patients with CRSwNP have a better outcome postoperatively than CRS without nasal polyposis patients. REFERENCES 1. Yip JM, Seiberlin KA, and Wormald PJ. Patient-reported olfactory function following endoscopic sinus surgery with modified endoscopic Lothrop procedure/draf 3. Rhinology 49: , Briner HR, Jones N, and Simmen D. Olfaction after endoscopic sinus surgery: Long-term results. Rhinology 50: , Nordin S, Blomqvist EH, Olsson P, et al.; NAF2S2 Study Group. Effects of smell loss on daily life and adopted coping strategies in patients with nasal polyposis with asthma. Acta Otolaryngol 131: , Damm M, Quante G, Jungehuelsing M, and Stennert E. Impact on functional endoscopic sinus surgery on symptoms and quality of life in chronic rhinosinusitis. Laryngoscope 112: , Neuland C, Bitter T, Marschner H, et al. Health-related and specific olfaction related quality of life in patients with chronic functional anosmia or severe hyposmia. Laryngoscope 121: , Blomquist EH, Lundblad L, Anggard A, et al. A randomized controlled study evaluating medical treatment versus surgical treatment in addition to medical treatment of nasal polyposis. J Allergy Clin Immunol 107: , Kim DW, Kim JY, and Jeon SY. The status of the olfactory cleft may predict postoperative olfactory function in chronic rhinosinusitis with nasal polyposis. Am J Rhinol Allergy 25:e90 e94, Hu B, Han D, Zhang L, et al. Olfactory event-related potential in patients with rhinosinusitis-induced olfactory dysfunction. Am J Rhinol Allergy 24: , Olsson P, and Stjarne P. Endoscopic sinus surgery improves olfaction in nasal polyposis, a multi-center study. Rhinology 48: , Rowe-Jones JM, and Mackay IS. A prospective study of olfaction following endoscopic sinus surgery with adjuvant medical treatment. Clin Otolaryngol Allied Sci 22: , Shin SH, Park JY, and Sohn JH. Clinical value of olfactory function tests after endoscopic sinus surgery: A short-term result. Am J Rhinol 13:63 66, Jankowski R, and Bodino C. Olfaction in patients with nasal polyposis: Effects of systemic steroids and radical ethmoidectomy with middle turbinate resection (nasalization). Rhinology 41: , Perry BF, and Kountakis SE. Subjective improvement of olfactory function after endoscopic sinus surgery for chronic rhinosinusitis. Am J Otolaryngol 24: , Litvack JR, Mace J, and Smith TL. Does olfactory function improve after endoscopic sinus surgery? Otolaryngol Head Neck Surg 140: , Ramadan HH. Surgical causes of failure in endoscopic sinus surgery. Laryngoscope 109:27 29, Shen PH, Weitzel EK, Lai JT, et al. Retrospective study of full-house functional endoscopic sinus surgery for revision endoscopic sinus surgery. Int Forum Allergy Rhinol 1: , Desrosiers MY, and Kilty SJ. Treatment alternatives for chronic rhinosinusitis persisting after ESS: What to do when antibiotics, steroids and surgery fail. Rhinology 46:3 14, Seiberling K, Floreani S, Robinson S, and Wormald PJ. Endoscopic management of frontal sinus osteomas revisited. Am J Rhinol Allergy 23: , Bassiouni A, Naidoo Y, and Wormald PJ. When FESS fails: The inflammatory load hypothesis in refractory chronic rhinosinusitis. Laryngoscope 122: , Shen PH, Weitzel EK, Lai JT, et al. Intravenous esmolol infusion improves surgical fields during sevoflurane-anesthetized endoscopic sinus surgery: A double-blind, randomized, placebo-controlled trial. Am J Rhinol Allergy 25 e208 e211, Rudmik L, and Smith TL. Olfactory improvement after endoscopic sinus surgery. Curr Opin Otolaryngol Head Neck Surg 20:29 32, Delank KW, and Stoll W. Olfactory function after functional endoscopic sinus surgery for chronic sinusitis. Rhinology 36:15 19, Eichel BS. Improvement of olfaction following pansinus surgery. ENT J 73: , Downey LL, Jacobs JB, and Lebowitz RA. Anosmia and chronic sinus disease. Otolaryngol Head Neck Surg 115:24 28, Seiden AM, and Smith DV. Endoscopic intranasal surgery as an approach to restoring olfactory function. Chem Senses 13:736, Minovi A, Hummel T, Ural A, et al. Predictors of the outcome of nasal surgery in terms of olfactory function. Eur Arch Otorhinolaryngol 265:57 61, McMains KC, and Kountakis SE. Revision functional endoscopic sinus surgery: Objective and subjective surgical outcomes. Am J Rhinol 19: , Bhattacharyya N. Clinical outcomes after revision endoscopic sinus surgery. Arch Otolaryngol Head Neck Surg 130: , Jiang RS, Su MC, Liang KL, et al. Preoperative prognostic factors for olfactory change after functional endoscopic sinus surgery. Am J Rhinol Allergy 23:64 70, Jiang RS, Lu FJ, Liang KL, et al. Olfactory function in patients with chronic rhinosinusitis before and after functional endoscopic sinus surgery. Am J Rhinol 22: , Katotomichelakis M, Gouveris H, Tripsianis G, et al. Biometric predictive models for the evaluation of olfactory recovery after endoscopic sinus surgery in patients with nasal polyposis. Am J Rhinol Allergy 24: , Katotomichelakis M, Riga M, Davris S, et al. Allergic rhinitis and aspirinexacerbated respiratory disease as predictors of the olfactory outcome after endoscopic sinus surgery. Am J Rhinol Allergy 23: , Litvack JR, Mace JC, and Smith TL. Olfactory function and disease severity in chronic rhinosinusitis. Am J Rhinol Allergy 23: , Yee KK, Pribitkin EA, Cowart BJ, et al. Neuropathology of the olfactory mucosa in chronic rhinosinusitis. Am J Rhinol Allergy 24: , Masaki M, and Tanaka Y. Nasal polyps in the olfactory cleft. Laryngoscope 108: , Min YG, Yun YS, Song BH, et al. Recovery of nasal physiology after functional endoscopic sinus surgery: Olfaction and mucociliary transport. ORL J Otorhinolaryngol Relat Spec 57: , Chang H, Lee HJ, Mo JH, et al. Clinical implication of the olfactory cleft in patients with chronic rhinosinusitis and olfactory loss. Arch Otolaryngol Head Neck Surg 135: , Georgalas C, Videler W, Freling N, and Fokkens W. Global Osteitis Scoring Scale and chronic rhinosinusitis: A marker of revision surgery. Clin Otolaryngol 35: , Knaapila A, Tuorila H, Kyvik K, et al. Self-ratings of olfactory function reflect odor annoyance rather than olfactory acuity. Laryngoscope 118: , Landis BN, Hummel T, Hugentobler M, et al. Ratings of overall olfactory function. Chem Senses 28: , Welge-Luessen A, Hummel T, Stojan T, and Wolfensberger M. What is the correlation between ratings and measures of olfactory function in patients with olfactory loss? Am J Rhinology 19: , Cervin A, and Wallwork B. Macrolide therapy of chronic rhinosinusitis. Rhinology 45: , Yamada T, Fujieda S, Mori S, et al. Macrolide treatment decreased the size of nasal polyps and IL-8 levels in nasal lavage. Am J Rhinol 14: , Cervin A. The anti-inflammatory effect of erythromycin and its derivatives, with special reference to nasal polyposis and chronic sinusitis. Acta Otolaryngol 121:83 92, Li LF, Lin MC, Yang CT, et al. Comparison of indoor allergens, allergic scores, and demographic data in Taiwanese adults with asthma or allergic rhinitis, or both. J Formos Med Assoc 98: , e e100 July August 2013, Vol. 27, No. 4

6 Copyright of American Journal of Rhinology & Allergy is the property of OceanSide Publications Inc. and its content may not be copied or ed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or articles for individual use.