International Rhinologic Society Rhinology 0300-0729 60 2 2022 4 1 35368049 Two years of COVID-19 â€" smell is still stealing the spotlight on the rhinology stage 81 81 EN C. Hopkins ENT Department, Guy’s Hospital, London, United Kingdom 2991 10.4193/Rhin22.902 It is hard to believe we are entering our third year of the COVID-19 pandemic; Rhinology was one of the first journals to highlight the association between COVID-19 and loss of smell and taste(1, 2) and articles on olfactory dysfunction (OD) continue to make up a significant proportion of our submissions. Lee et al. present detailed electron microscopy images showing loss of the normal olfactory epithelial architecture, with the invading SARS-CoV-2 virus clearly pictured. Bhutani et al. studied self- reported loss of smell after COVID-19 infection, finding similar rates in those with and without obesity, which add further ‘weight’ against a higher prevalence of loss of sense of smell in more severe COVID-19 disease.

International Rhinologic Society Rhinology 0300-0729 60 2 2022 4 1 34783797 Prolonged breastfeeding and protective effects against the development of allergic rhinitis: a systematic review and meta-analysis 82 91 EN M.P. Hoang Department of Otolaryngology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Endoscopic Nasal and Sinus Surgery Excellent Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Department of Otolaryngology, Hue University of Medicine and Pharmacy, Hue University, Vietnam J. Samuthpongtorn Department of Anatomy, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand K. Seresirikachorn Department of Otolaryngology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Endoscopic Nasal and Sinus Surgery Excellent Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand K. Snidvongs Department of Otolaryngology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Endoscopic Nasal and Sinus Surgery Excellent Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand 2948 10.4193/Rhin21.274 Background: There is insufficient evidence to confirm the protective effects of prolonged breastfeeding against the development of allergic rhinitis (AR). Methodology: A systematic review and meta-analysis was performed to assess the associations between prolonged breastfeeding and AR symptoms later in life. Comparisons were conducted between breastfeeding durations less than 6 months and 6 months or more and between less than 12 months and 12 months or more. Exclusive breastfeeding and nonexclusive breastfeeding were analysed separately. Outcomes were risks of AR development later in life. Results: Twenty-three observational studies (161,611 children, age 2-18 years, 51.50% male) were included. Two studies (9%) were with high quality. Both exclusive and nonexclusive prolonged breastfeeding (6 months or more) decreased the risk of AR. The long-term (12 months or more) nonexclusive breastfeeding lowered the likelihood of AR compared to the 12 months or fewer. The long-term exclusive breastfeeding did not show the same protective effect; however, this result was restricted to only one study. Conclusions: Exclusive breastfeeding and nonexclusive breastfeeding for 6 months or more may have protective effects against the development of AR up to 18 years of age. The findings should be interpreted with caution given the limitation of low-quality observational studies.

International Rhinologic Society Rhinology 0300-0729 60 2 2022 4 1 35199801 Role of spreader flaps in primary rhinoplasty, functional and aesthetic outcomes: a systematic review 92 101 EN K. Garefis 2nd Academic ORL, Head and Neck Surgery, Department Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki, Greece I. Konstantinidis 2nd Academic ORL, Head and Neck Surgery, Department Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki, Greece N. Tsetsos Department of ORL, Head and Neck Surgery, G. Papanikolaou Hospital, Thessaloniki, Greece M. Garefi Department of Pediatric, General Hospital of Veroia, Veroia, Greece V. Nikolaidis 2nd Academic ORL, Head and Neck Surgery, Department Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki, Greece K. Markou 2nd Academic ORL, Head and Neck Surgery, Department Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki, Greece 2971 10.4193/Rhin21.235 Background: The standard treatment for reconstructing the middle vault of the nose is to use spreader grafts. Recently, an alternative technique using spreader flaps has become widely accepted. Methodology: A literature search was performed in ÎœEDLINE, Science Direct, the Cochrane Library and multiple trial registries. The systematic review included studies evaluating the effectiveness of spreader flaps, with or without comparison to the spreader graft technique, in patients who had undergone primary rhinoplasty. Results: Thirteen studies with a total of 500 patients met the inclusion criteria and were reviewed systematically. All studies measured breathing function improvement. Additionally, aesthetic improvement/satisfaction was evaluated in seven studies. The use of spreader flaps seems to improve breathing function, as seen in twelve out of thirteen studies. Furthermore, the studies assessing the aesthetic aspect of a primary rhinoplasty showed that spreader flaps can provide satisfactory results. The comparison between spreader flaps and spreader grafts showed similar results in most studies dealing with this topic in both the breathing function improvement and aesthetic improvement/satisfaction domains. Conclusions: This study is the first systematic review assessing the functional and aesthetic outcomes of spreader flaps in primary rhinoplasty, and it shows encouraging results comparable to those of spreader grafts.

International Rhinologic Society Rhinology 0300-0729 60 2 2022 4 1 35167627 Nasal polyp load determines the recovery of olfaction after surgery for chronic rhinosinusitis 102 108 EN B.R. Haxel Department of Otolaryngology, Head and Neck Surgery, Schwarzwald-Baar Klinikum Villingen-Schwenningen, Germany; Department of Otolaryngology, Head and Neck Surgery, University Medical Center of the Johannes Gutenberg University Mainz, Germany L. Fischer Smell and Taste Clinic, Department of Otorhinolaryngology, Technische Universität Dresden, Dresden, Germany J. Pade Department of Otorhinolaryngology, St. Johannes Municipal Hospital, Dortmund, Germany J. Reden Smell and Taste Clinic, Department of Otorhinolaryngology, Technische Universität Dresden, Dresden, Germany T. Hummel Smell and Taste Clinic, Department of Otorhinolaryngology, Technische Universität Dresden, Dresden, Germany 2964 10.4193/Rhin21.361 Background: Chronic rhinosinusitis (CRS) is typically accompanied by impairment of olfaction. Despite of this, until today the efficacy of endonasal sinus surgery (ESS) in terms of olfactory function is still unclear. So far it is known that patients with nasal polyps are most likely to experience post-operative recovery. Within the present study we investigated the sense of smell and other parameters of impairment in CRS before and after ESS in relation to the degree of nasal polyposis, determined with the nasal endoscopic Lildholdt-score. Methods: Patients with different degrees of severity of nasal polyposis were included. Olfactory function was assessed for odor thresholds [T], odor discrimination [D] and odor identification [I] and the changes of these parameters were investigated postoperatively. Results: For 72 patients baseline measures were available and in 47 patients, postoperative changes were described. There was a correlation between olfactory scores and nasal anatomy/polyposis scores (Lildholdt scores, Lund-Mackay CT score), rated nasal health, and nasal quality of life (sinonasal outcome test). Three months after surgery the average TDI-Score improved by 3.1 points with 30% of patients showing significant clinical improvement. Patients with severe polyposis (Lildholdt score of 5 or 6) benefited most in terms of olfaction. Other significant prognostic indicators of a postoperative increase of olfactory scores included younger age, low pre-operative TDI-scores and high CT-scores. Conclusions: This study shows that not only the presence of polyps in CRS, but also the degree of nasal polyposis - measured by a grading system - predicts the results in olfactory test results. Additionally, the degree of recovery of olfaction after ESS seems to be most relevant in patients with high polyp scores.

International Rhinologic Society Rhinology 0300-0729 60 2 2022 4 1 35112673 Twelve-year long-term postoperative outcomes in patients with chronic rhinosinusitis with nasal polyps 109 117 EN C. Arancibia Rhinology and Skull Base Unit, Department of Otorhinolaryngology, Hospital Clinic, Universitat de Barcelona, Spain C. Langdon Rhinology and Skull Base Unit, Department of Otorhinolaryngology, Hospital Clinic, Universitat de Barcelona, Spain; Institut dInvestigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias (CIBERES), Barcelona, Spain J. Mullol Rhinology and Skull Base Unit, Department of Otorhinolaryngology, Hospital Clinic, Universitat de Barcelona, Spain; Institut dInvestigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias (CIBERES), Barcelona, Spain I. Alobid Rhinology and Skull Base Unit, Department of Otorhinolaryngology, Hospital Clinic, Universitat de Barcelona, Spain; Institut dInvestigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias (CIBERES), Barcelona, Spain 2959 10.4193/Rhin21.148 Background: Evidence regarding long-term postoperative follow-up of chronic rhinosinusitis with nasal polyps (CRSwNP) patients is scarce in the literature. The objective of the present study was to report long-term 12-year postoperative outcomes for CRSwNP patients. Methods: CRSwNP patients were prospectively followed after endoscopic sinus surgery. Sinonasal symptoms, nasal polyp score (NPS), Barcelona Smell Test 24 (BAST-24), Lund-Mackay Score (LMS), and Medical Outcome Study Short Form-36 (SF-36) questionnaire were assessed before and 12 years after surgery. Results: At long-term follow-up (median, 12 years), a strong improvement was noted for all patients (N=76) in nasal symptoms score, NPS, BAST-24, and LMS scores compared with baseline. No long-term improvement in SF-36 was found. Conclusion: Patients with CRSwNP have a long-term 12-year postoperative improvement in nasal symptoms, polyp size, computed tomography, and olfaction.

International Rhinologic Society Rhinology 0300-0729 60 2 2022 4 1 Long-term histopathological changes of the nasal mucosa after total laryngectomy: a prospective cohort study 118 127 EN M.O. Tomoum Department of Otorhinolaryngology, Faculty of Medicine, University of Tanta, Tanta, Egypt M.F. Abdelaziz Department of Otorhinolaryngology, Faculty of Medicine, University of Tanta, Tanta, Egypt A. Younes Department of Otorhinolaryngology, Faculty of Medicine, University of Tanta, Tanta, Egypt H. El-Afandi Department of Otorhinolaryngology, Faculty of Medicine, University of Tanta, Tanta, Egypt M. Sheta Department of Otorhinolaryngology, El-Mahalla general hospital, Tanta, Egypt M.M. Elkelany Department of Histology, Faculty of Medicine, University of Tanta, Tanta, Egypt A. El-Naggar Department of Otorhinolaryngology, Faculty of Medicine, University of Tanta, Tanta, Egypt 2960 10.4193/Rhin21.284 Background: Changes in the nasal function following total laryngectomy resulted in histopathological alterations of the nasal mucosa. We aimed to evaluate the long-term histopathological changes and the mucociliary clearance (MCC) of the nasal mucosa after total laryngectomy. Methods: We performed a histological examination of inferior turbinate biopsy, and saccharine test to assess the MCC time for patients who were candidates for total laryngectomy before the procedure, 6-12 months after surgery, and at least two years postoperatively. Results: Seventy-five patients scheduled for total laryngectomy were initially enrolled in our study. We excluded patients who received postoperative radiotherapy or were lost during the follow-up period. Eventually, 63 and 54 patients were available for assessment 6-12 months after surgery and at least two years postoperatively, respectively. Except for ciliary and goblet cell destruction, which were significantly reduced 6-12 months postoperatively, there were no statistically significant differences in the histopathological findings of the nasal mucosa before surgery and 6-12 months postoperatively. After two years, the histopathological alterations of the nasal mucosa were statistically more evident than those before surgery and 6-12 months postoperatively; the most common histopathological findings were mononuclear cell infiltration and stromal fibrosis. The mean MCC time preoperatively was 12.56 minutes that statistically significantly decreased to 11.81 minutes 6-12 months after surgery; then, it significantly increased to 20.98 minutes at least two years postoperatively. Conclusions: After total laryngectomy, the nasal mucosa showed histopathological alterations and early enhancement of the MCC, which was later impaired due to nasal mucosal atrophy and the saprophytic infection.

International Rhinologic Society Rhinology 0300-0729 60 2 2022 4 1 35191431 COVID-19 related chemosensory changes in individuals with self-reported obesity 128 138 EN S. Bhutani School of Exercise and Nutritional Sciences, San Diego State University, San Diego, CA, USA G. Coppin Department of Psychology, Formation Universitaire à Distance (UniDistance), Brig, Switzerland; Swiss Center for Affective Sciences, University of Geneva, Geneva, Switzerland M.G. Veldhuizen Department of Anatomy, Faculty of Medicine, Mersin University, Mersin, Turkey V. Parma Department of Psychology, Temple University, Monell Chemical Senses Center, Philadelphia, PA, USA P.V. Joseph National Institutes of Alcohol Abuse and Alcoholism and National Institute of Nursing Research, Bethesda, MD, USA 2968 10.4193/Rhin21.351 Background/objectives: Self-reported smell loss is a prominent symptom of COVID-19 infection and a potentially useful clinical tool for remote pre-screening of this disease. However, pre-existing chemosensory dysfunction with obesity may diminish the usefulness of self-reported smell loss in this vulnerable group. Here we aim to compare COVID-19 related chemosensory alterations in participants with and without obesity and determine if self-reported smell loss is predictive of lab-based COVID-19 diagnosis in both groups in the context of restrictive clinical data collection. Subjects/methods: In this secondary analysis of a cross-sectional global dataset, we compared self-reported chemosensory ability in participants with a respiratory illness reporting a positive (C19+; n = 5156) or a negative (C19-; n = 659) COVID-19 laboratory test outcome, who also self-reported to have obesity (C19+; n = 433, C19-; n = 86) or not. Results: Participants with obesity and without obesity reported a similar decline in smell, taste, and chemesthesis during illness. In C19+ participants with obesity, we observed a greater relative prevalence of non-chemosensory symptoms, including respiratory and GI symptoms. Critically, we found that the model previously proposed also predicts C19+ diagnosis in participants with obesity. Conclusions: We conclude that COVID-19 respondents with obesity experience a similar self-reported chemosensory loss as those without obesity. In both groups self-reported chemosensory symptoms are similarly predictive of COVID-19 infection, thus highlighting the potential of collecting self-report of symptoms and comorbidities remotely when clinical observations are restrictive.

International Rhinologic Society Rhinology 0300-0729 60 2 2022 4 1 35112672 Omega-3 supplementation in postviral olfactory dysfunction: a pilot study 139 144 EN A.K. Hernandez Smell and Taste Clinic, Department of Otorhinolaryngology, TU Dresden, Dresden, Germany D. Woosch Smell and Taste Clinic, Department of Otorhinolaryngology, TU Dresden, Dresden, Germany A. Haehner Smell and Taste Clinic, Department of Otorhinolaryngology, TU Dresden, Dresden, Germany T. Hummel Smell and Taste Clinic, Department of Otorhinolaryngology, TU Dresden, Dresden, Germany 2958 10.4193/Rhin21.378 Background: This study aimed to examine whether omega-3 supplementation would support olfactory recovery among postviral olfactory dysfunction patients. Methodology: Patients with postviral olfactory dysfunction were included in this non-blinded, prospective pilot study. Structured medical history was taken from the patients, including the following: age, sex, history of COVID-19 infection, and duration of symptoms. Patients were randomly assigned to receive olfactory training only (control group) versus olfactory training with omega-3 supplementation (treatment group). All patients exposed themselves twice a day to four odours (phenyl ethyl alcohol [rose], eucalyptol [eucalyptus], citronellal [lemon], and eugenol [cloves]). Olfactory function was measured before and after training using “Sniffin’ Sticks�, comprised of tests for odour threshold, discrimination, and identification. The average interval between olfactory tests was 3 months. Results: Fifty-eight patients were included in the study, 25 men and 33 women. Generally, an improvement in olfactory scores was observed. Compared to the control group, the improvement in odour thresholds was more pronounced in the omega-3 group. Age, sex, and duration of symptoms had no effect on olfactory scores among both control and treatment groups. Conclusion: Overall, the present results indicate that omega-3 supplementation may be an option for adjunct therapy with olfactory training in patients with postviral olfactory dysfunction.

International Rhinologic Society Rhinology 0300-0729 60 2 2022 4 1 35167628 Midline olfactory implantation: a cadaveric study of endoscopic transseptal transcribriform approach 145 147 EN H. Benkhatar Centre Hospitalier de Versailles, Service d’ORL et chirurgie cervico-faciale, Le Chesnay-Rocquencourt, France; Ecole de Chirurgie du Fer à Moulin, Paris, France C. Loubieres Centre Hospitalier de Versailles, Service d’ORL et chirurgie cervico-faciale, Le Chesnay-Rocquencourt, France; Ecole de Chirurgie du Fer à Moulin, Paris, France A.R. Kada Centre Hospitalier de Versailles, Service d’ORL et chirurgie cervico-faciale, Le Chesnay-Rocquencourt, France; Ecole de Chirurgie du Fer à Moulin, Paris, France M. De Malherbe Centre Hospitalier de Versailles, Service de Radiologie, Le Chesnay-Rocquencourt, France N. Meunier Université Paris-Saclay, INRAE, UVSQ, VIM, Jouy-en-Josas, France 2965 10.4193/Rhin21.376

International Rhinologic Society Rhinology 0300-0729 60 2 2022 4 1 35174813 Respiratory epithelial adenomatoid hamartoma with nasal polyps affects dupilumab efficacy 148 151 EN T. Takeda Department of Otorhinolaryngology, Jikei University School of Medicine, Japan N. Yanagi Department of Otorhinolaryngology, Jikei University School of Medicine, Japan N. Fukasawa Department of Pathology, Jikei University School of Medicine, Japan E. Mori Department of Otorhinolaryngology, Jikei University School of Medicine, Japan M. Maeda Department of Otorhinolaryngology, Jikei University School of Medicine, Japan R. Sakaguchi Department of Pathology, Jikei University School of Medicine, Japan M. Tei Department of Otorhinolaryngology, Jikei University School of Medicine, Japan K. Omura Department of Otorhinolaryngology, Jikei University School of Medicine, Japan N. Otori Department of Otorhinolaryngology, Jikei University School of Medicine, Japan 2967 10.4193/Rhin21.359

International Rhinologic Society Rhinology 0300-0729 60 2 2022 4 1 Why is there such variation in nasal cautery rates for childhood epistaxis: deprivation or clinician behaviour? National data from Scotland 2000-2019 152 154 EN L. Downie Scottish Public Health Observatory, Public Health Scotland, Glasgow, United Kingdom H. Kubba Paediatric Otolaryngology, Royal Hospital for Children, Glasgow, United Kingdom 2938 10.4193/Rhin

International Rhinologic Society Rhinology 0300-0729 60 2 2022 4 1 35112671 COVID-19: Extensive epithelial damage and ciliary dyskinesia in hospitalised patients 155 158 EN D.D.H. Lee UCL Great Ormond Street Institute of Child Health, UCL and NIHR GOSH BRC, London, U.K D. Cardinale UCL Great Ormond Street Institute of Child Health, UCL and NIHR GOSH BRC, London, U.K Y. Saman Department of ENT, University Hospitals of Leicester, Leicester, UK R.A. Hirst Centre for PCD Diagnosis and Research, Department of Respiratory Sciences, University of Leicester, Leicester, U.K N. Wilson Cellular Pathology Department, University Hospitals of Leicester, Leicester, U.K. V. Corden Cellular Pathology Department, University Hospitals of Leicester, Leicester, U.K. A. Rutman Centre for PCD Diagnosis and Research, Department of Respiratory Sciences, University of Leicester, Leicester, U.K T. de Haro Cellular Pathology Department, University Hospitals of Leicester, Leicester, U.K. R.E. Hynds UCL Cancer Institute, University College London, U.K T. McHugh UCL Centre for Clinical Microbiology, University College London, U.K. P. Rea Department of ENT, University Hospitals of Leicester, Leicester, UK C.M. Smith UCL Great Ormond Street Institute of Child Health, UCL and NIHR GOSH BRC, London, U.K. C. O’Callaghan UCL Great Ormond Street Institute of Child Health, UCL and NIHR GOSH BRC, London, U.K.; Centre for PCD Diagnosis and Research, Department of Respiratory Sciences, University of Leicester, Leicester, U.K. 2961 10.4193/Rhin21.233 Infection with SARS-CoV-2 can cause severe respiratory disease and it is predicted that the COVID-19 pandemic will leave a substantial number of patients with long-term respiratory complications (1).

International Rhinologic Society Rhinology 0300-0729 60 2 2022 4 1 35099479 Classification of eCRS: Based on disease outcome or normal range?: Comment on Toro et al. 159 160 EN L. Pan Department of Otolaryngology-Head and Neck Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P.R. China Z. Liu Department of Otolaryngology-Head and Neck Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P.R. China 2957 10.4193/Rhin21.343 Undoubtedly, there is a lack of unanimous histopathologic criteria to classify eosinophilic chronic rhinosinusitis (eCRS) worldwide. We read with great interest the recent constructive systematic review by Toro et al.(1). The authors stretched out the current knowledge on the methods of classifying eCRS to determine an optimal cut-off point. While the authors are to be congratulated for their comprehensive overview, a point regarding the disease recurrence as the most relevant parameter to divide eosinophilic and noneosinophilic inflammation in chronic rhinosinusitis (CRS) should be discussed. In order to contribute to an evidence-based standardization of cut-off point to classify eCRS, we would like to share our considerations and approaches in this comment.