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New Guidelines for Rhinoplasty, BPPV, Cerumen Impaction Developed

AAO-HNSF has developed three new clinical practice guidelines for the management of rhinoplasty, benign paroxysmal positional vertigo (BPPV), and cerumen impaction that were reviewed in Miniseminars during the Annual Meeting. The guidelines are expected to be published next year.

The Clinical Practice Guidelines presentations will be a part of a new AcademyU Education Activity called the Annual Meeting Expert Series (AmX). Each activity includes the video recording of the presentation, a post interview with the faculty, a clinical case exercise, and a post-test; up to five CME credits may be awarded upon passing the post-test. Purchase these at www.academyu.org.

Clinical Practice Guideline: Improving Nasal Form and Function after Rhinoplasty
The guideline on rhinoplasty includes 10 key action steps as part of its evidence-based recommendations to improve outcomes of the surgical procedure. A 15-member multidisciplinary panel developed the guideline key action steps, said Lisa E. Ishii, MD, MHS, chair of the panel. Those steps including talking to patients before surgery about their expectations, educating patients about pain control, the use of antibiotics and steroids, and chronic medical conditions to be considered before performing rhinoplasty.

“We were able to make some exciting recommendations, particularly about antibiotics, steroids, and assessment of patient expectations. We are excited about the new recommendations because they are important areas for quality improvement. Everyone who participates in the care of patients undergoing rhinoplasty should attend to learn about them,” said Dr. Ishii, an associate professor at Johns Hopkins School of Medicine Department of Otolaryngology-Head and Neck Surgery

In 2014, more than 200,000 procedures were reported to correct nasal deformities and anatomic variations linked to nasal obstruction and airway compromise, and to improve nasal aesthetics.

“Rhinoplasty is a very common procedure in this country. We needed to have a way to make recommendations based on evidence to optimize the quality of care we provide,” Dr. Ishii said. “Ultimately, we will be able to standardize care better in areas where we know it is appropriate.”

Clinical Practice Guideline (Update): Benign Paroxysmal Positional Vertigo
BPPV is the most common vestibular problem treated by physicians. An AAO-HNSF panel has updated the BPPV clinical practice guideline, which was published in 2008, even though most of its recommendations remain valid, said Neil Bhattacharyya, MD, chair of the guideline update panel.

“We have had a significant increase in the body of evidence for BPPV, with 20 new systematic reviews and 27 controlled trials,” said Dr. Bhattacharyya, professor of otology & laryngology at Harvard Medical School. “The new guideline has a patient algorithm to help clinicians at the point of care. We are emphasizing more patient education and shared decision-making, which is a big topic in newer guidelines.”

The original guideline focused on posterior canal BPPV while the update adds more information about lateral canal BPPV because of an increase in diagnostic information and treatment recommendations for it.

“What we really want to do with this guideline is emphasize a very effective treatment option that oftentimes can be done in the same sitting as the initial diagnosis,” Dr. Bhattacharyya said. “This guideline goes through the positional maneuvers that can effectively cure the vertigo in upwards of 80 percent of patients.

“We emphasized the canalith repositioning procedure (CRP), which now has a ‘strong recommendation’ for treatment because the evidence is overwhelmingly positive about its effectiveness.”

Another recommendation is to forgo imaging studies in obvious cases of BPPV.

“For cost savings and safety, we are recommending against getting any imaging in straightforward cases,” Dr. Bhattacharyya said. “They don’t need a CT scan or MRI. We also recommended against treating with medicines that are vestibular suppressants because they have side effects, and CRP is very effective.”

One final change is the addition of a Key Action Statement that patients do not need to have their activities restricted following treatment for BPPV.

Clinical Practice Guideline: Cerumen Impaction
Cerumen impaction is a relatively benign condition that affects a lot of people—between 6 million and 18 million in the United States. Managing that many patients requires updated information, so the guidelines include references to new literature, new action statements, and a new algorithm for the management of patients, said Seth R. Schwartz, MD, MPH, chair of the guideline update panel and moderator of the session.

“New literature in the last six or seven years sheds additional light on the topic,” said Dr. Schwartz, director of the Listen for Life Center at Virginia Mason Medical Center, Seattle, WA. “We included information about new randomized trials, systematic reviews, and some observational studies.

“We have brought this up to the current standard of guideline development, which is to make them more comprehensive, more transparent, and more in-line with the recommendations from the National Academies of Sciences, Engineering, and Medicine (formerly the Institute of Medicine) for developing trustworthy guidelines. We also included a patient representative on the panel.”

The guideline includes three new action statements:

  • A renewed emphasis on primary prevention among patients at risk for the condition, including commentary for patients to take greater care in cleaning ears. It is recommended they avoid the use of cotton-tipped applicators, bobby pins, and sharp objects because of the potential for harm.
  • A recommendation against ear candling now has its own statement to emphasize the message. Previously, the recommendation was part of another statement.
  • It is recommended that patients who do not have a good response to initial treatment be referred for advanced therapy and that the impaction be managed until it is resolved.

Recommendations for the diagnosis and management of cerumen impaction in the guideline have no significant changes, Dr. Schwartz said. The primary management strategies are to use irrigation, drops, or manual removal of cerumen with instrumentation.

“There is a new algorithm for walking clinicians through the management of these patients, starting with presenting with cerumen or with symptoms related to cerumen,” he said. “It walks through how you would manage the patient, with references to the different guideline statements to make it more user-friendly, including pictures and illustrations.”

One area of emphasis is for young children or cognitively impaired adults who cannot communicate their symptoms. The guideline recommends more aggressive management for removal of cerumen because these patients may not be able to complain about impaction, Dr. Schwartz said.

Even though the guideline does not break new ground scientifically, it was important to update it to deal with such a common condition.

“The point is that we, as the specialists in this area, want to take ownership of this,” Dr. Schwartz said. “The guideline is much more for primary care clinicians who are typically the first line of treatment for these patients.

“We are the stewards of this knowledge and the ultimate endpoint for care when patients have more complicated issues related to cerumen impaction. That is why the Academy has taken ownership of this and feels it is important to have a guideline about it.”

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