2018 Section 5 - Rhinology and Allergic Disorders

Batra et al.

studied may receive a radiation dose ranging from 15 mSv in an adult to 30 mSv in a neonate from a single imaging study with an average of 2 to 3 CT scans per study. These doses likely do confer a small risk for radiation-induced carcinogenesis. They further extrapolated that a head CT at these doses results in a lifetime attributable risk of death from cancer ranging from 0.075% for CT exposure as a neonate to 0.01% for CT exposure when the patient was 15 years old. To place this in a broader context, it is esti- mated that up to 2% of all cancers in the United States may be attributable to radiation from CT imaging. As the con- cept of CT-induced malignancy risk continues to become more widespread, it is imperative for otolaryngologists to be well informed and able to thoughtfully answer ques- tions and concerns posed by their patients. This important knowledge gap merits further discussion at future AAO- HNS and ARS educational courses. Statistical analysis of key respondent variables provides further insightful information in the CT practice patterns. Otolaryngologists that have been in clinical practice for a decade are statistically less likely to obtain a CT scan to verify presence of sinusitis after medical therapy or to rule out sinusitis in the headache patient. It is conceivable that these practitioners may have greater comfort with the clin- ical diagnosis because they have more clinical experience. In contrast, physicians in academic practice are more likely to obtain a CT scan after 1 round of medical therapy. It is possible that this may be related to the complexity of a tertiary care referral practice, requiring confirmation with imaging to ensure an accurate diagnosis in patients who may already have been evaluated by other practitioners. Interestingly, physicians with an in-office CT scanner were statistically more likely to obtain a confirmatory CT scan prior to initiating therapy. This may stem from the need for an accurate diagnosis prior to starting treatment, espe- cially with ready access to imaging on site. Though this does not necessarily imply overutilization in the strictest sense, it does underscore the need for judicious use of imaging as the acquisition paradigm transitions from the hospital to the office setting. Further, geographic location also influ- ences acquisition of CT imaging after 1 round of medical therapy. The South Central region is the most likely to do so, whereas the Mid-Atlantic is the least likely. The ex- act reasons for these observations are not afforded by the available dataset and represent an important area of future study.

Important limitations of the survey must be acknowl- edged. The respondents represent a select group of oto- laryngologists with a significant portion of their clinical practice devoted to rhinology. Further, the responders may be more likely than nonresponders to manage sinus dis- ease, and may feel they have a greater stake in the sur- vey. Their responses may not represent the CT imaging patterns of the wider otolaryngology community. The pos- sibility of recall bias must also be considered. The respon- dents may inaccurately estimate the CT usage patterns. The survey represents the opinions of the participants and the coauthors’ interpretations of the available data; it does not serve to reflect the views of the AAO-HNS or the ARS on utility of CT imaging in adult CRS. Nonetheless, the current survey should provide a platform for ongoing dis- cussion on the importance of CT imaging in management of adult CRS to enhance care of these patients, while ad- dressing concerns about overutilization, cost, and radiation exposure. Conclusion This survey provides a snapshot into the usage patterns of CT imaging in the medical and surgical management schema of adult CRS. The survey group included otolaryn- gologists with wide range of length and type of clinical prac- tice and broad geographic representation. The responses suggest that most participants use CT imaging judiciously. The majority of respondents did not obtain confirmatory CT imaging prior to initiating medical therapy for CRS, whereas most participants obtained on average 1 or 2 CT scans prior to proceeding with primary FESS. An in-office CT scanner, most commonly CBCT, was owned by one- fourth of the respondents. A majority of respondents were unaware of the dosage of radiation delivered by the scan- ner used for CT acquisition. Though this preliminary sur- vey data is enlightening and encouraging, close monitoring will be required with ongoing adaptation of in-office CT platforms. Acknowledgments We are grateful to Jenna Kappel and Joseph Cody, AAO- HNS staff, and Kevin Welch, MD, the ARS Informational Technology Committee Chair, for the logistical support to help conduct the survey.

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9. American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) and Amer- ican Medical Association (AMA)-convened Physician Consortium for Performance Improvement R (PCPI TM ). Adult Sinusitis Performance Measurement Set (July 2, 2012). http://www.ama- assn.org/resources/doc/pcpi/sinusitis.measures.pdf. Accessed January 2, 2014. 10. Tan BK, Chandra RK, Conley DB, Tudor RS, Kern RC. A randomized trial examining the effect of pre- treatment point-of-care computed tomography imag- ing on the management of patients with chronic rhinosinusitis symptoms. Int Forum Allergy Rhinol . 2011;1:229–234.

5. Setzen G, Ferguson BJ, Han JK, et al. Clinical consen- sus statement: appropriate use of computed tomog- raphy for paranasal sinus disease. Otolaryngol Head Neck Surg . 2012;147:808–816. 6. Brenner DJ, Hall EJ. Computed tomography—an in- creasing source of radiation exposure. N Engl J Med . 2007;357:2277–2284. 7. Fazel R, Krumholz HM, Wang Y, et al. Exposure to low-dose ionizing radiation from medical imaging procedures. N Engl J Med . 2009;361:849–857. 8. Bhattacharyya N. Trends in otolaryngologic utiliza- tion of computed tomography for sinonasal disorders. Laryngoscope . 2013;123:1837–1839.

International Forum of Allergy & Rhinology, Vol. 5, No. 6, June 2015

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