The annual Institute for Scientific Information (ISI) journal rankings were recently released and the International Forum of Allergy and Rhinology (IFAR) has performed extremely well, with an impact factor of 2.37 and a ranking of #6 among all ear, nose, and throat (ENT) journals. This is an outstanding result for such a new journal and reflects very well on the editorial team and the quality of the articles submitted. In this issue, the relationship between important quality-of-life aspects such as sleep quality and olfaction and sinus surgery are presented. In the article by Alt et al.,1 the Pittsburgh Sleep Quality Index (PSQI) is used as the outcome measure to assess the effectiveness of endoscopic sinus surgery (ESS) on improving sleep quality. It was notable that 72% of patients undergoing ESS for chronic rhinosinusitis (CRS) had poor sleep quality and that surgery improved the sleep quality significantly. This improvement underpins the value of ESS, as it is well recognized that poor sleep significantly impairs the physical, psychological, and social well-being of the patient. Following the theme of impairments that significantly affect quality of life is an article by DeConde et al.,2 who looked at the oft forgotten symptom of decreased sense of smell in patients undergoing both medical and surgical treatment for CRS. Interestingly, the benefit seemed to be similar in both the medically and surgically treated cohorts, with 38% returning to a normal sense of smell. Surprisingly, patients with nasal polyps did not seem to improve any more than patients in the nonpolyp cohort. Moving into the realm of evidence-based medicine, the review of the literature regarding the medical treatment of allergic fungal sinusitis patients after surgery is presented by Gan et al.3 ESS again plays an important role in the management of this difficult to manage CRS subtype by removing the disease load and the consequent antigenic stimulation and opening the sinuses so that the ongoing management with topical medication can be optimized. This article reviews the various treatment options and recommends the use of oral steroids in the postoperative period. However, it is not clear what dose, for how long, and how often this treatment can be used without significant side effects; the article states that its use should be judicious and limited to short courses, but states that exact recommendations

DOI: 10.1002/alr.21409 View this article online at wileyonlinelibrary.com. How to Cite this Article: Wormald PJ. IFAR makes an impact. Int Forum Allergy Rhinol. 2014;4:691–692.


International Forum of Allergy & Rhinology, Vol. 4, No. 9, September 2014

can only be made if larger randomized controlled trials are performed. The other recommendation is for topical steroids, but it is well known that the traditional topical steroid spray does not penetrate the postoperative sinus cavities and the effect is limited. However, the recent popularization of the off-label use of high-dose topical steroids reflects their effectivity, but this article states that the published evidence for this treatment remains inconclusive and it can only be recommended as an option. Also falling into the “option” category for selected recalcitrant cases are oral antifungals and immunotherapy. The lack of clearly defined treatment recommendations reflects the difficulty for surgeons in managing this group of patients and reinforces the feeling that surgeons are often grasping at straws for definitive treatment options. Another topic of interest is frontal ostial patency after Draf III.4 In this article, the authors address the potential contributing factors of re-stenosis after surgery by correlating re-stenosis (neo-osteogenesis and/or soft tissue) with the global osteitis score (GOS), disease load (Lund-Mackay), endoscopy scores (Lund-Kennedy), serum eosinophilia, and previous ESS. Interestingly enough, only the GOS showed any correlation. Also interesting is that the average size of ostial reduction was 50% and that the biggest contributor to this closure was the soft tissue. This reinforces the dictum that the bigger the neo-ostium at the time of surgery the less likely it is that the subsequent narrowing will become symptomatic. One option that should be considered is the use of free mucosal grafts on the anterior wall, as this may break this soft tissue cicatrization and lessen re-stenosis.5 As the role of the endoscope in the management of skullbase tumors strengthens, articles on the increased incidence of pituitary tumors6 and the demographics and survival trends in sinonasal adenocarcinoma7 reflect this new paradigm. It is likely that the increased availability of magnetic resonance imaging (MRI) has led to the increased detection and thus incidence of pituitary tumors. It is also interesting that more and more of these cases are now performed endoscopically, with increasingly better outcomes. Similarly, recent publications have shown an increased role for endoscopic resection in adenocarcinoma patients. It is also important to reflect that with the endoscope playing such an important role around delicate neural structures, attention must be paid to the heat generated from the tip of the endoscope and the role that endoscope irrigators may play in lessening the temperature generated at the tip.8 A significant addition to this journal is the Allergy Primer Supplement.9–23 This supplement provides a comprehensive review of allergy in the practice of ENTs. The supplement

covers topics from a comprehensive overview on immunology, including the innate and adaptive immune responses and nasal epithelial immunity, to information about relevant history and examination and skin testing. The supplement also reviews immunodeficiency, its common presentations, and tests needed to diagnose these conditions, and continues on to the pharmacotherapy for allergic rhinitis, sublingual immunotherapy, and avoidance and control measures for allergen management. Finally, a review of the

role of asthma in ENT clinical practice and the role of surgery in allergic rhinitis is presented. This review is an excellent overview, provides a refresher for all practicing ENT surgeons, and is highly recommended to our readers.

Peter John Wormald, MD Associate Editor

References 1.





Alt JA, Smith TL, Schlosser RJ, Mace JC, Soler ZM. Sleep and quality of life improvements after endoscopic sinus surgery in patients with chronic rhinosinusitis. Int Forum Allergy Rhinol. 2014;4:693– 701. DeConde AC, Mace JC, Alt JA, Scholler RJ, Smith TL, Soler ZM. Comparative effectiveness of medical and surgical therapy on olfaction in chronic rhinosinusitis: a prospective, multi-institutional study. Int Forum Allergy Rhinol. 2014;4:725–733. Gan EG, Thamboo A, Rudmik L, Hwang P, Ferguson B, Javer A. Medical management of allergic fungal rhinosinusitis following endoscopic sinus surgery: an evidence-based review and recommendations. Int Forum Allergy Rhinol. 2014;4:702–715. Ye T, Hwang PH, Huang Z, et al. Frontal ostium neoosteogenesis and patency after Draf III procedure: a computer assisted study. Int Forum Allergy Rhinol. 2014;4:739–744. Hildenbrand T, Wormald PJ, Weber RK. Endoscopic frontal sinus drainage Draf type III with mucosal transplants. Am J Rhinol Allergy. 2012;26:148– 151.




9. 10. 11. 12.


Villwock JA, Villwock M, Deshaies E, Goyal P. Significant increases of pituitary tumors and resections from 1993 to 2011. Int Forum Allergy Rhinol. 2014;4:767– 770. D’Aguillo CM, Kanumuri VV, Khan MN, et al. Demographics and survival trends of sinonasal adenocarcinoma from 1973 to 2009. Int Forum Allergy Rhinol. 2014;4:771–776. Craig J, Goyal P. Insulating and cooling effects of nasal endoscope sheaths and irrigation. Int Forum Allergy Rhinol. 2014;4:759–762. Lin SY. Allergy primer. Int Forum Allergy Rhinol. 2014;4:S17. Mims JW. Epidemiology of allergic rhinitis. Int Forum Allergy Rhinol. 2014;4:S18–S20. Toskala E. AAOA allergy primer: immunology. Int Forum Allergy Rhinol. 2014;4:S21–S27. Franzese CB. AAOA allergy primer: history and physical examination. Int Forum Allergy Rhinol. 2014;4:S28–S31. Krouse HJ. Environmental controls and avoidance measures. Int Forum Allergy Rhinol. 2014;4:S32–S34.

14. Platt M. Pharmacotherapy for allergic rhinitis. Int Forum Allergy Rhinol. 2014;4:S35–S40. 15. Fornadley JA. Skin testing for inhalant allergy. Int Forum Allergy Rhinol. 2014;4:S41–S45. 16. Osguthorpe JD. In vitro allergy testing. Int Forum Allergy Rhinol. 2014;4:S46–S50. 17. Roche AM, Wise SK. Subcutaneous immunotherapy. Int Forum Allergy Rhinol. 2014;4:S51–S54. 18. Lin SY. Sublingual immunotherapy: current concepts for the U.S. practitioner. Int Forum Allergy Rhinol. 2014;4:S55–S59. 19. Leatherman BD. Anaphylaxis in the allergy practice. Int Forum Allergy Rhinol. 2014;4:S60–S65. 20. Lee S. Practical approach to the allergy patient. Int Forum Allergy Rhinol. 2014;4:S66–S69. 21. Reisacher WR. Asthma and the otolaryngologist. Int Forum Allergy Rhinol. 2014;4:S70–S73. 22. Ryan MW. AAOA Allergy Primer: immunodeficiency. Int Forum Allergy Rhinol. 2014;4:S74–S78. 23. Chhabra N, Houser SM. Surgery for allergic rhinitis. Int Forum Allergy Rhinol. 2014;4:S79–S83.

International Forum of Allergy & Rhinology, Vol. 4, No. 9, September 2014


Editorial: the annual Institute for Scientific Information(ISI).

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