To Think Outside the Box Requires Stepping Outside of Your Comfort Zone

It was a surprise and privilege to be asked to write the editorial for this issue of American Journal of Rhinology and Allergy. In my training to become a skull base neurosurgeon, I personally benefitted tremendously learning not only from neurosurgeons, but also from rhinologists, head and neck surgeons, neuro-otologists, and reconstructive surgeons. The articles in this issue provide a wonderful overview of topics from the diagnosis, pathophysiology, and treatment of disease, to anatomical considerations, and finally some practical social and medicolegal considerations. What I enjoyed most about this issue is both the familiar feel of certain topics and the deep reflection that comes with exploring those which are less familiar. These sentiments reminded me of my skull base training in that to truly learn to think outside of my neurosurgical box, it required actually stepping out of my neurosurgical comfort zone. The global prevalence of allergic rhinitis and chronic rhinosinusitis is increasing. Our basic understanding of the immunologic changes and their impact on the pathophysiology of sinus disease continues to evolve as evidenced by numerous works presented.1–4 Environmental exposures and changing climate may be playing a role. Airborne pollutant material has been associated with pulmonary and cardiovascular problems. In an in vitro study of nasal epithelial cells, Park and colleagues noted that urban particulate matter may induce a stress response on the endoplasmic reticulum and nasal epithelia tight junctions; the response may be a potential therapeutic target. In a study of patients treated at their center, Patel et al. postulated that air pollutant exposure may be associated with histopathology findings in chronic rhinosinusitis by studying patients in the Chicago area and surrounding counties. While a possible association was found, the authors correctly pointed out that this did not equate to causality. With increased understanding of pathophysiology at a basic level, pathologic changes may actually be more easily detectable in less invasive way. Park and co-workers provided a nice example of this in their study of nasal lavage biomarkers in allergic rhinitis patients. Biological changes in the global environment have occurred rapidly in the COVID-19 pandemic and Sehanobish and colleagues add to this growing literature. Ultimately, as the global population increases and urbanization continues, a more detailed understanding of the pathophysiology of sinus disease, the impact of changing environmental factors, and exploring easier and less invasive diagnostic strategies will be critical to effectively manage sinus diseases. Periodic scrutiny of current diagnostic tools and established treatment strategies sheds light on where continued improvement opportunities lie. Amirneni and Tversky did this for allergy skin prick testing by comparing the dosage of histamine control reagents. Despite being routinely used and part of established practice, utilizing a higher histamine dose was associated with a significantly lower sensitivity; raising the question of whether standardization of the histamine control reagent doses should be considered. In their review of recurrent acute rhinosinusitis, Saltagi and co-workers concluded that despite increased interest in this disease, the level of evidence that exists is largely expert opinion due to a lack of consensus. In the same vein, Calvo-Henriquez and colleagues found the evidence too limited to recommend maxillary expansion as a primary treatment option for nasal breathing. For acute pediatric sinusitis with intracranial complications, Chorney and group found that frontal sinus drainage was of unclear benefit. These three studies highlight the challenges faced in evaluating evidence of surgical interventions. Specifically that the tools and study designs we employ may not be ideally suited to answer the questions we pose. Randomized-controlled trials when equipoise exists or well-designed prospective registries to explore rare problems may allow differences in individual practice patterns to be evaluated with a higher degree of Editorial