International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors

BACKGROUND

Sinonasal neoplasms, whether benign and malignant, pose a significant challenge to clinicians and represent a model area for multidisciplinary collaboration in order to optimize patient care. The International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors (ICSNT) aims to summarize the best available evidence and presents 48 thematic and histopathology-based topics spanning the field.

METHODS

In accordance with prior International Consensus Statement on Allergy and Rhinology documents, ICSNT assigned each topic as an Evidence-Based Review with Recommendations, Evidence-Based Review, and Literature Review based on the level of evidence. An international group of multidisciplinary author teams were assembled for the topic reviews using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses format, and completed sections underwent a thorough and iterative consensus-building process. The final document underwent rigorous synthesis and review prior to publication.

RESULTS

The ICSNT document consists of four major sections: general principles, benign neoplasms and lesions, malignant neoplasms, and quality of life and surveillance. It covers 48 conceptual and/or histopathology-based topics relevant to sinonasal neoplasms and masses. Topics with a high level of evidence provided specific recommendations, while other areas summarized the current state of evidence. A final section highlights research opportunities and future directions, contributing to advancing knowledge and community intervention.

CONCLUSION

As an embodiment of the multidisciplinary and collaborative model of care in sinonasal neoplasms and masses, ICSNT was designed as a comprehensive, international, and multidisciplinary collaborative endeavor. Its primary objective is to summarize the existing evidence in the field of sinonasal neoplasms and masses.

Opiate vs non-opiate prescription medication for pain control after endoscopic sinus surgery for chronic rhinosinusitis

PURPOSE

Research indicates that most providers give opiates after endoscopic sinonasal surgery. The effectiveness of non-opiate medications after sinonasal surgery is poorly understood and most studies do not assess medication failure. This study compares oral opiate, oral opiate and topical steroid, and oral non-opiate pain control. Patient call-backs are used as a proxy for pain medication failure.

MATERIALS AND METHODS

This study compares three medication regiments after sinonasal surgery for 180 adults with chronic rhinosinusitis. Patients were instructed to take acetaminophen for mild pain. For moderate/severe pain, patients used: 1) oxycodone-acetaminophen, 2) oxycodone-acetaminophen + budesonide nasal rinses, or 3) meloxicam + acetaminophen. Patients were instructed to call clinic if pain was not controlled. Descriptive statistics compared cohorts. Chi-square tests compared call-backs between cohorts. Logistic regression adjusted for baseline differences in covariates, comorbidities, and operative sites.

RESULTS

Cohorts had similar age, sex distribution, disease features, and extent of surgery. The meloxicam cohort had less subjects with pain disorders. The oxycodone cohort had less subjects with diabetes, septoplasty, and turbinate reduction. After adjusting for baseline differences and using oxycodone as the reference group (n = 50), the odds of calling clinic for poorly controlled pain was 0.18 (95% Confidence Interval (CI): 0.05-0.6) in the meloxicam cohort (n = 45) and 0.19 (95% CI:0.07-0.5) in the oxycodone + budesonide rinses cohort (n = 85).

CONCLUSION

In this study, both meloxicam and oxycodone + budesonide rinses were more effective at controlling pain after sinonasal surgery than oxycodone alone.

Chronic Rhinosinusitis Disease Disparity in the South Florida Hispanic Population

OBJECTIVES/HYPOTHESIS

The role of social determinants of health in chronic rhinosinusitis (CRS) is poorly characterized. Limited research examining CRS health disparities indicates that minority status is associated with worse CRS. However, many of these studies are retrospective or performed in populations without substantial ethnic minorities. Rhinologists need to characterize existing CRS disease disparities to develop targeted strategies for improving care in these populations. This prospective study assesses preoperative CRS disease burden in South Florida (SFL) Hispanic and non-Hispanic patients and examines potential factors contributing CRS disease disparities.

STUDY DESIGN

Prospective cohort study.

METHODS

The prospective cohort study included consecutive patients having primary endoscopic sinus surgery (ESS) for CRS between September 2019 and February 2020 with complete preoperative data. Data were collected in clinic and surgery. Descriptive statistics compare Hispanic and non-Hispanic cohorts. Linear regression adjusts for confounders. Relative risk (RR) compared CRS severity markers.

RESULTS

Thirty-eight Hispanic and 56 non-Hispanic patients met inclusion criteria. Age, sex, CT scores, insurance payer, and comorbidities were similar between cohorts. Hispanics presented with worse 22-item Sinonasal Outcome Test (SNOT-22) (55; SD = 18) compared to non-Hispanics (37; SD = 22) (P < .001). Hispanics tended to have a higher risk of severe CRS markers, including nasal polyps RR = 2.5 (95% CI: 1.0-5.9), neo-osteogenesis RR = 1.6 (95% CI: 0.5-4.7), extended procedures (i.e., draft III) RR = 2.97 (95% CI: 1.0-9.1), and tissue eosinophilia RR = 1.46 (95% CI: 0.6-3.5). Hispanics reported longer sinonasal symptom duration.

CONCLUSIONS

SFL hispanic patients presenting for primary ESS have worse sinonasal disease burden. SFL Hispanics have markers of greater CRS severity and report longer delays before receiving CRS care. These factors may contribute to increased sinonasal disease burden in Hispanic patients.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:2659-2665, 2021.

ICAR: endoscopic skull-base surgery

BACKGROUND

Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS).

METHODS

Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated.

CONCLUSION

A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.

Ethical surgical triage of patients with head and neck cancer during the COVID-19 pandemic

BACKGROUND

Coronavirus has serially overtaken our metropolitan hospitals. At peak, patients with acute respiratory distress syndrome may outnumber mechanical ventilators. In our Miami Hospital System, COVID-19 cases have multiplied for 4 weeks and elective surgery has been suspended.

METHODS

An Otolaryngologic Triage Committee was created to appropriately allocate resources to patients. Hospital ethicists provided support. Our tumor conference screened patients for nonsurgical options. Patients were tested twice for coronavirus before performing urgent contaminated operations. N95 masks and protective equipment were conserved when possible. Patients with low-grade cancers were advised to delay surgery, and other difficult decisions were made.

RESULTS

Hundreds of surgeries were canceled. Sixty-five cases screened over 3 weeks are tabulated. Physicians and patients expressed discomfort regarding perceived deviations from standards, but risk of COVID-19 exposure tempered these discussions.

CONCLUSIONS

We describe the use of actively managed surgical triage to fairly balance our patient's health with public health concerns.

Role of Adjunct Treatments for Idiopathic CSF Leaks After Endoscopic Repair

OBJECTIVE

A higher incidence of recurrent cerebrospinal fluid (CSF) leaks has been reported with idiopathic CSF leaks. A growing number of institutions advocate for routine use of intracranial pressure-lowering adjunct treatments after endoscopic repair. We report our results in a patient cohort in which only symptomatic patients are subjected to further testing and treatment.

STUDY DESIGN

Retrospective review.

METHODS

A retrospective review of patients who underwent endoscopic transnasal repair of idiopathic CSF rhinorrhea was performed at the University of Miami, Florida, from July 2010 to July 2017. The database was queried for demographical data, surgical details, radiological findings, and postoperative outcomes. Only patients with greater than a 12-month follow-up were included.

RESULTS

Thirty-three patients underwent endoscopic repair of an idiopathic CSF leak. Twenty-six (79%) were females, with an average age of entire study population being 48 years. The average body mass index (BMI) of the cohort was 33 kg/m² , with 89% being overweight (BMI > 25 kg/m² ). The skull base defect was found to be mainly at the cribriform plate (64%) and sphenoid sinus (30%). Endoscopic repair was performed successfully as a single repair in 32 patients (97%). The average follow-up was 47 months. Postoperative adjunct medications were used on four patients (12%) with symptomatic idiopathic intracranial hypertension.

CONCLUSION

Endoscopic repair of idiopathic CSF leaks was found to have a high rate of success in our study. Postoperatively, only four patients required additional measures to medically reduce symptomatic intracranial hypertension. Routine postoperative adjunct treatments are unnecessary and may expose patients to adverse long-term side effects.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:41-47, 2021.

Nasolacrimal Duct Management During Endoscopic Sinus and Skull Base Surgery

OBJECTIVE

To evaluate rates of epiphora after transection and marsupialization of the nasolacrimal duct (NLD) during endoscopic sinus and skull base surgery.

INTRODUCTION

The nasolacrimal canal forms part of the medial wall of the maxillary sinus. Transecting the NLD is sometimes necessary for tumor resection or surgical access to maxillary sinus and infratemporal fossa pathology. There is no consensus for the endoscopic management of the NLD when only the duct is transected without involving the nasolacrimal sac.

METHODS

Medical records of 29 patients from 2 academic institutions who underwent endoscopic sinus and skull base surgery with transection of the NLD were retrospectively reviewed. Whether the duct was marsupialized or simply transected was recorded, and the postoperative rate of epiphora was calculated.

RESULTS

Mean age was 59 years (range, 14-86 years). Mean follow-up was 10.5 months (range, 1-33 months). The NLD was marsupialized in 16 (55%) and simply transected in 13 (45%) patients. Six patients underwent postoperative radiation. No patients in the marsupialization group had epiphora postoperatively, all with Munk score of 0. One patient in the transection group developed postoperative epiphora with Munk score of 1. Pathology included inverted papilloma (8), acute on chronic inflammation (6), B-cell lymphoma (3), juvenile nasopharyngeal angiofibroma (2), squamous cell carcinoma (2), Schneiderian papilloma (2), metastatic melanoma (1), HPV-related carcinoma (1), adenocarcinoma (1), benign epithelial cyst (1), adenoid cystic carcinoma (1), and erosive chronic sinusitis without nasal polyposis (1).

CONCLUSION

Management after transection of the NLD varies widely. The duct may be simply transected or marsupialized, or a formal dacryocystorhinostomy can be performed. The surgeon must also choose whether to place a stent. Based on our small series and review of the literature, marsupialization or simple transection of the NLD results in a low rate of postoperative epiphora in the setting of endoscopic sinus and skull base surgery.

Somatization, Depression, and Anxiety Disorders in a Rhinology Practice

Background

Patients present to rhinology clinics with various complaints. Symptoms may be attributable to objective findings, some remain unexplained. The objective is to investigate the incidence of psychological disorders in a rhinologic practice and evaluate a correlation of these psychiatric diseases with rhinologic symptoms.

Methods

Patients presenting to a rhinology clinic were administered the Generalized Anxiety Disorder 7 (GAD 7), Patient Health Questionnaire 9 (PHQ 9), and PHQ 15, psychometric instruments that can screen for generalized anxiety, major depression, and somatization disorder, respectively. Patients’ symptoms, endoscopic findings, medication, and psychiatric history were recorded. Multivariable analysis was performed for patients showed moderate-to-severe anxiety, depression, and somatic symptoms via 3 logistic regressions where the outcome was a GAD 7, PHQ 9, or PHQ 15 above 10.

Results

One hundred ninety-six patients were included for this study. There were 109 females and 87 males with a mean age of 49 years. Overall, 9%, 14%, and 21% exhibited moderate-to-severe anxiety, depressive, and somatization symptoms, respectively. Nasal obstruction was the only statistically significant variable that increased the odds of having moderate-to-severe anxiety symptoms. Similarly, headache, nasal obstruction, and anosmia/hyposmia were associated with increased odds of having depressive symptoms, and female gender, headache, and nasal discharge increased the odds of somatic symptom disorder. Edema was the only objective endoscopic finding, which was associated with depression only.

Conclusions

Patients should be counseled about the pathophysiology and psychiatric comorbidities affecting their primary rhinologic complaints. The provider needs to set realistic treatment expectations in order to achieve the desired clinical outcomes.

Nasal branch of the anterior ethmoid artery: a consistent landmark for a midline approach to the frontal sinus

BACKGROUND

Frontal sinusotomy can be challenging when significant scarring or distorted anatomy is present. Identifying a reliable anatomic structure, when traditional landmarks or navigation are absent, may assist the surgeon in revision and complicated frontal sinusotomies via a midline approach. We aimed to characterize the anatomic relationship of the nasal branch of the anterior ethmoid artery (NBAEA) to the frontal infundibulum, specifically the first olfactory fili, posterior frontal infundibulum, and anterior cribriform plate.

METHODS

Dissection of the NBAEA was carried out in 11 cadaveric heads, resulting in a total of 21 dissections (1 aplastic frontal). Mean with standard deviation and a range were established for 7 relative measurements.

RESULTS

The total length of NBAEA cleft when present (mean 2.43 mm), the anterior edge of NBAEA cleft to anterior infundibulum coronal plane (mean 1.71 mm), the posterior edge of NBAEA cleft to posterior infundibulum coronal plane (mean 3.33 mm), the posterior edge of NBAEA cleft to 1st olfactory fili (mean 2.86 mm), and the first olfactory fili to posterior infundibulum coronal plane (mean 0.48 mm) were consistent measurements supporting the use of the NBAEA as a consistent anatomical landmark for the correct surgical coronal trajectory into the midline frontal sinus.

CONCLUSION

The NBAEA is a consistent anatomic landmark with minimal intercadaveric and intracadaveric variation. It can be used reliably as a "sentinel artery" notifying the surgeon when one is approaching the first olfactory fili, to determine the correct trajectory into the midline frontal sinus.

Volumetry in the Assessment of Pituitary Adenoma Resection: Endoscopy versus Microscopy

Background  Assessment of the extent of resection after surgical resection of pituitary adenomas is most commonly reported in terms of the presence or absence of residual tumor. A quantitative comparison of volumetric resection between endonasal endoscopy (EE) and microsurgery (MS) has rarely been done. Methods  A retrospective analysis was performed on a consecutive series of 154 patients with pituitary adenomas treated by the same surgeon at a single institution. We employed volumetric analysis pre- and postoperatively on two cohorts of pituitary adenoma patients treated through MS ( n  = 37) versus EE approach ( n  = 117). Results  Volumetric analysis revealed a higher incidence of complete resection (64.4 vs. 56.8%) and mean volume reduction in the EE cohort (92.7 vs. 88.4%), although not significant. Recurrence rates were significantly lower in the EE group (7.7% vs 24.3%, p  = 0.015). Subgroup analysis identified that patients with preoperative tumor volumes >1 mL were less likely to recur through EE (7.8 vs. MS: 29.6%; p  = 0.0063). A higher incidence of complete resection was also noted in patients with favorable Knosp grades (0-1) (EE: 87.8 vs. MS: 63.2%; p  = 0.036). Postoperative complication rates were not significantly different between both techniques. Conclusion  Both microscopy and endoscopy are well-tolerated, effective approaches in the treatment of pituitary adenomas. Our series demonstrated that EE may be superior to MS in preventing tumor recurrence and achieving a complete resection in certain subsets of patients. EE provides a slight advantage in tumor control outcomes that may justify the paradigm shift to pure endoscopy at our center.

Endoscopic Resection of Esthesioneuroblastoma

Esthesioneuroblastoma (olfactory neuroblastoma) is a rare malignant neoplasm originating from neuroepithelial cells. Treatment for this tumor has traditionally required a craniofacial resection through an external approach. The safety and efficacy of transnasal endoscopic resection is unknown. A series of five patients with Kadish stage A or B lesions of the anterior skull base were resected and immediately reconstructed endoscopically over a nine-year period. There were 2 males and 3 females with a mean age of 64 years. Three patients were treated primarily and two were treated secondarily for recurrences after failing a traditional external craniofacial resection and postoperative radiotherapy. All primary lesions received adjuvant radiotherapy. The mean follow-up time was 31 months. All patients were discharged within 4 days or less. Operative complications included temporary postoperative infraorbital anesthesia (1 patient), unplanned cerebrospinal fluid leak (1 patient), and an orbital hematoma (1 patient). None of these complications resulted in any permanent sequelae. Two patients had prolonged nasal crusting for up to one year due to a variety of factors; large cavities, radiation therapy, and exposed lyophilized dural graft. However, all skull base defects healed without any short- or long-term sequelae. There have been no local recurrences. Two patients (1 primary and 1 secondary) developed regional metastasis to the orbit or cervical lymph nodes managed with primary transorbital excision or modified neck dissection, respectively. All but one patient remain free of disease by clinical, endoscopic, and radiographic (CT or MRI) surveillance. The remaining patient recurred distally as an undifferentiated carcinoma in his temporal bone and lungs 12 months after the initial resection. In experienced hands select cases of esthesioneuroblastoma can be safely excised and reconstructed endoscopically with comparable degrees of tissue removal as with external approaches. Short-term oncologic results in this small series of patients appear to be comparable to traditional methods. Longer follow-up on a larger series of patients is warranted.

Reliability of the University of Miami Chronic Rhinosinusitis Staging System

Background

The aim of this study was to determine the interrater reliability and correlation between computed tomography (CT) and endoscopic components of the University of Miami (UM) Chronic Rhinosinusitis Staging System (UMCRSS), a comprehensive staging system for chronic rhinosinusitis (CRS).

Methods

A prospective analysis of 55 patients undergoing endoscopic sinus surgery for CRS was performed. The population consisted of 28 men and 27 women, with a mean age of 45.9 years. All patients underwent staging, via the CT and endoscopic components of the UMCRSS in the operating room, by three examiners. The reliability of the system and all of its components was determined by K-coefficient analysis, comparing the data from all three examiners. Correlation between the CT and endoscopic arms was analyzed by Pearson's product moment coefficient.

Results

Interrater reliability for the CT arm (κ = 0.83) and endoscopic arm (κ = 0.74 for the revision population, and κ = 0.72 for the primary surgery population) were found to be significant. Endoscopic staging established significant correlation with CT staging (Pearson's r2 = 0.40; p < 0.0001 overall, 0.57, p < 0.0001 for revision, and 0.42, p < 0.0001 for primary cases).

Conclusion

The UMCRSS is a comprehensive and reliable staging system with very strong and positive correlation between the CT and endoscopic components.

Revision Functional Endoscopic Sinus Surgery

Refractory chronic rhinosinusitis can be challenging to treat. Initial treatment focuses on medical and nonsurgical treatments. If these treatments fail, revision endoscopic sinus surgery is an option. A plan for revision surgery must address anatomic factors contributing to recurrence. Preoperative imaging and sinonasal endoscopy are systematically reviewed; areas of disease and "danger" zones are identified. Traditional anatomic landmarks are often obscured or absent; thus, a set of consistent landmarks (unchanged despite prior surgery) are used to navigate the revision endoscopic sinus surgery. Wide sinusotomies permit visualization and access to disease intraoperatively. Large sinus openings also facilitate post-operative debridements in clinic, endoscopic disease monitoring, and topical sinus therapy.

Endoscopic Resection of Sinonasal and Ventral Skull Base Malignancies

The transnasal endoscopic resection of ventral skull base lesions represents a safe and effective method for the surgical management of sinonasal and ventral skull base malignancies in carefully selected cases. The goal of surgery is complete removal of all tumor with negative resection margins while maintaining the key oncological principles. Careful selection of cases along with the presence of an experienced surgeon and a fully involved multidisciplinary skull base team trained in the management of ventral skull base neoplasm are essential for excellent outcomes.

Tissue model and preliminary analysis of microdebriders used in functional endoscopic sinus surgery

OBJECTIVE: To develop a standardized in vitro tissue model for microdebrider comparison, and determine which microdebrider, tissue type, blade type, and suction strength is most efficient.

STUDY DESIGN AND SETTING: A prospective randomized comparison of the Diego Powered Dissector and XPS 3000 Powered ENT System was conducted using a soft-tissue and a firm-tissue model. In addition to evaluating tissue aspiration with straight and angled blades, clogging rates and clearance times were measured. Both standard wall suction and liposuction were used. Basic statistical analysis and a one-way analysis of variance using confidence intervals were performed to compare outcomes.

RESULTS: The aspiration of soft tissue was statistically superior to and demonstrated less clogging compared to the aspiration of firm tissue. For the “head-to-head” comparison, the XPS 3000 was statistically superior for aspirating soft tissue. When liposuction was excluded, the devices were essentially equivalent. Several notable trends that were not statistically significant were also observed. The aspiration efficiency of straight blades appeared to be superior compared to angled blades. The XPS 3000 and liposuction independently seemed to aspirate more tissue than the Diego Powered Dissector and regular suction, but at the expense of increased clogging. Finally, the Diego Powered Dissector showed a trend toward aspirating more firm tissue.

CONCLUSION: Our tissue model represents a reliable and reproducible means of microdebrider comparison. A secondary analysis with a larger sample size is warranted to further validate the tissue model, to improve the power of the statistically significant results, and to better delineate the trends that were observed in the current study.

The effect of endoscopic olfactory cleft polyp removal on olfaction

BACKGROUND

The presence of olfactory cleft polyps in chronic rhinosinusitis with nasal polyposis is well documented, but the effect of endoscopic olfactory cleft polyp surgery on olfaction, versus observation, has not been well studied. This analysis assessed if microdebridement of olfactory cleft polyps yields significant objective smell improvements in those with anosmia or hyposmia.

METHODS

A randomized prospective single-blinded study was performed on patients undergoing bilateral endoscopic sinus surgery with profound bilateral nasal polyposis, excluding those younger than 18 years or without olfactory polyps. A preoperative University of Pennsylvania Smell Identification Test (UPSIT), visual analog scale (VAS), and sinonasal outcomes 20 score (SNOT-20), and a follow-up at 6 months was performed. Two cohorts were created, including one with cleft polyp removal (group A) and one with cleft polyps left in place (group B).

RESULTS

There were 10 patients in group A and 7 in group B. By using the Wilcoxon signed rank test, the two groups were individually analyzed for changes in the preoperative UPSIT, VAS, and SNOT-20 versus the 6-month test results. In group A, the improvement in the UPSIT, VAS, and SNOT-20 were statistically significant at p < 0.05. For group B only the improvement in the VAS was statistically significant, at p < 0.05. There was a statistically significant difference in clinical smell improvement between group A and B at 6 months (p = 0.00512).

CONCLUSIONS

Evidence exists that olfactory cleft polyp surgery improves olfactory function outcomes. Long-term data beyond 6 months is needed to further validate these early promising outcomes.

Spontaneous CSF rhinorrhea: prevalence of multiple simultaneous skull base defects

BACKGROUND

Spontaneous cerebrospinal fluid (CSF) leaks are caused by intracranial hypertension. Given this underlying etiology, patients may be at risk for developing multiple skull base defects.

OBJECTIVE

The purpose of our study is to present the prevalence of multiple simultaneous skull base defects in patients with spontaneous CSF rhinorrhea.

METHODS

We performed a retrospective chart review in a tertiary care practice of 44 consecutive patients with spontaneous CSF rhinorrhea who underwent endoscopic repair by the senior author (R.R.C.) to determine the prevalence of having multiple simultaneous skull base defects identified at the time of surgery. We defined this as two or more bony defects identified endoscopically with intact intervening bone with or without soft tissue prolapse into the nasal cavity or paranasal sinus cavity.

RESULTS

Eight of 44 patients (18.2%) were found to have multiple simultaneous skull base defects. The average body mass index (BMI) of the study population was 34.5 (range, 22.7-59).

CONCLUSION

A significant number of patients with spontaneous CSF rhinorrhea may have more than one skull base defect present at the time of presentation. The clinical significance of this finding in surgical and medical decision making is not clear at this time.

Managing Cerebrospinal Fluid Rhinorrhea after Lateral Skull Base Surgery via Endoscopic Endonasal Eustachian Tube Closure

Background

A cerebrospinal fluid (CSF) leak, commonly presenting as rhinorrhea, is a well-recognized complication of lateral skull base surgery. Failure of conservative treatment measures in these cases necessitates surgical intervention.

Objective

Our aim is to demonstrate that endoscopic endonasal closure of the eustachian tube is a reasonable alternative to more traditional techniques for management of recalcitrant postoperative CSF rhinorrhea after removal of middle and posterior cranial fossa lesions.

Methods

A retrospective chart review was performed for patients who presented with CSF rhinorrhea after lateral skull base surgery at a tertiary medical center over a 17-year period, from 1997 to 2014. Nine patients managed with endoscopic endonasal closure of the eustachian tube were evaluated for preoperative hearing status, approach to lateral skull base surgery, pathology, size and location of the tumor, timing and presentation of CSF leak, methods of treatment, length of hospital stay, complications, and success of the procedure.

Results

Of the nine patients included in this review, seven were managed successfully with endoscopic endonasal eustachian tube closure. Of those seven, one required a revision procedure. Average length of postoperative stay was 5.8 days. There were no major complications. Follow up of greater than 100 months has been achieved since the first procedure.

Conclusion

Endoscopic endonasal eustachian tube closure is a safe, minimally invasive and effective method for obliteration of the eustachian tube orifice. The algorithm for management of recalcitrant postoperative CSF rhinorrhea after lateral skull base surgery should include endoscopic endonasal closure of the eustachian tube.

Endoscopic Anterior Skull Base Resection: University of Miami Experience

Objectives:

To report: (1) Oncological safety of endoscopic technique using disease free survival and a Kaplan Maier analysis for malignant tumors and recurrence rate for benign tumors; (2) Type of reconstruction of large anterior skull base defects and rate of postoperative cerebrospinal fluid leak; (3) Postoperative major (cranial and orbital) and minor complications.

Methods:

Retrospective chart review identifying patients undergoing endoscopic anterior skull base resection for malignant and benign tumors at a tertiary care medical center between September 1997 and June 2013.

Results:

Preliminary analysis shows that 34 patients underwent transnasal endoscopic resection for malignant disease and 2 patients for benign disease. The median follow-up was 30 months. Olfactory neuroblastoma was the most common pathology. There were 3 major and 5 minor complications. Three patients recurred locally resulting in a local control rate of 90.9%. The overall mortality rate was 18%, and the disease specific mortality was 3%. Reconstruction of the skull base defect was done using acellular dermis as a sole graft with a success rate of 97% and a cerebrospinal fluid leak in 1 case.

Conclusions:

Endoscopic anterior skull base resection for benign or malignant disease is a safe and valid alternative compared to standard approaches. It is gaining more popularity, and with increasing surgical expertise, the indications of this procedure are expanding.

Tackling Problematic Chronic Rhinosinusitis: Technical Pearls on Optimizing Outcomes from Endoscopic Sinus Surgery

Program Description:

Failure of adequate response to endoscopic sinus surgery (ESS) is a frequent cause of frustration to chronic rhinosinusitis patients and their surgeons. Technical execution of ESS may be a factor in some common findings at revision ESS (middle meatal adhesions, lateralized middle turbinate, missed maxillary ostium, residual uncinate process, residual anterior and posterior ethmoid cells, sphenoid ostium stenosis, and frontal recess scarring). Using real-life demonstrative cases, our expert panel will share practical and key technical pearls on optimizing results from ESS. These include simple modifications in surgical techniques, selection of procedure appropriate to disease, and incorporation of state-of-the-art technology (endoscopes, instrumentation, navigation, etc).

Educational Objectives:

(1) Recognize technical causes of failure of satisfactory response from ESS. (2) Implement changes in surgical techniques to optimize technical execution of ESS. (3) Learn to use technology and instrumentation to improve execution and completeness of ESS.

Distant pseudomeningoceles of the ventral skull base: a report of 2 cases

BACKGROUND

The objective of this case series was to report what is to the best of our knowledge the first reports of nasopharyngeal and soft palate pseudomeningoceles tracking submucosally from the sphenoid sinus.

METHODS

Analysis of cases through medical records.

RESULTS

Two cases of middle-aged male patients presented to our tertiary care university teaching hospital for recurrent meningitis and a history of cerebrospinal fluid (CSF) rhinorrhea. Both were found to have pseudomeningoceles distant from the sphenoid sinus. One was tracking to the mucosa of the Eustachian tube, and the other to the dorsum of the soft palate. Both were found to be tracking submucosally from the sphenoid sinus, to the vidian canal, to the lateral nasopharyngeal wall, to their respective locations at the Eustachian tube and dorsum of the soft palate. CSF closure was performed with a transnasal endoscopic repair using the pedicled nasoseptal flap for 1 patient and Alloderm for the other, both with successful cessation of CSF rhinorrhea.

CONCLUSION

We present these cases of distant spontaneous CSF leaks. We review the literature and discuss case management.

Endoscopic identification of the pharyngeal (palatovaginal) canal: an overlooked area

Objective The pharyngeal or palatovaginal canal (PC) is a small tunnel that lies between the sphenoid process of the palatine bone and the vaginal process of the sphenoid bone. Currently, little endoscopic information is available about this region. Design and Setting Endoscopic endonasal cadaveric study. Subjects and Methods Twenty sides in 10 adult cadaver heads were studied endoscopically. The sphenopalatine foramen (SPF) and the adjacent pterygopalatine fossa were exposed. Dissection medial to the vidian canal demonstrated a tunnel that runs posteromedially in the sphenoid floor. Endoscopic data were documented. Additionally, canal measurements were obtained on 20 sides from coronal CT scans of paranasal sinuses. Results The PC was identifiable in 85% of the sides, although thickness of its bony wall was variable. The endoscopic relationship of the canal and its artery with other landmarks is described. Radiologically, the diameter of the PC averaged 1.7 mm, and the mean distance from the PC to the vidian canal was 3.78 mm. Conclusion The current study provides a novel endoscopic identification of an overlooked canal. The pharyngeal artery can be a source of bleeding during extended endoscopic procedures. The PC itself could be a place for finger-like projections of anatomically related neoplasms.

Surgical nuances for the endoscopic endonasal transpterygoid approach to lateral sphenoid sinus encephaloceles

Lateral sphenoid encephaloceles of the Sternberg canal are rare entities and usually present with spontaneous CSF rhinorrhea. Traditionally, these were treated via transcranial approaches, which can be challenging given the deep location of these lesions. However, with advancements in endoscopic skull base surgery, including improved surgical exposures, angled endoscopes and instruments, and novel repair techniques, these encephaloceles can be resected and successfully repaired with purely endoscopic endonasal approaches. In this report, the authors review the endoscopic endonasal transpterygoid approach to the lateral recess of the sphenoid sinus for repair of temporal lobe encephaloceles, including an overview of the surgical anatomy from an endoscopic perspective, and describe the technical operative nuances and surgical pearls for these cases. The authors also present 4 new cases of lateral sphenoid recess encephaloceles that were successfully treated using this approach.

Considerations for Initial Dosing of Botulinum Toxin in Treatment of Adductor Spasmodic Dysphonia

Objectives

To assess the effect on voice improvement and duration of breathiness based on initial dose of onabotulinum toxin A (BTX-A) in the management of adductor spasmodic dysphonia (SD) and to compare voice outcomes for initial bilaterally injected doses of 1.25 units (group A) vs 2.5 units (group B) of BTX-A.

Study Design

Case series with chart review of patients with adductor SD treated at a tertiary care facility from 1990 to 2011.

Setting

Academic subspecialty laryngology practice.

Methods

Demographic data (age and sex), voice rating, duration of voice improvement, and breathiness were evaluated and compared between groups A and B using the Student t test and χ2 analysis.

Results

Of 478 patients identified, 305 (223 in group A, 82 in group B) patients met inclusion criteria. The average age was 56.2 years in group A and 57.4 years in group B ( P = .5). The female to male ratio was 2.91 for group A vs 3.56 for group B ( P = .61). Good voice outcomes (grade 3 or 4) were reported by 91% of group A patients vs 94% of group B ( P = .75). The average duration of voice improvement was 99.7 days for group A and 108.3 days for group B ( P = .54). The average duration of breathiness was 10.88 days for group A vs 15.42 days for group B ( P = .02).

Conclusion

Patients injected with 1.25 units bilaterally had a statistically significant shorter duration of breathiness without a statistically significant difference in clinical effectiveness or voice outcome. It is therefore recommended that a relatively low initial BTX-A dose be used with subsequent titration to achieve improved voice outcomes.

Modified subtotal lothrop procedure for extended frontal sinus and anterior skull base access: a cadaveric feasibility study with clinical correlates

Objective The endoscopic modified Lothrop procedure (EMLP) is an established approach for recalcitrant frontal sinus disease and anterior skull base exposure. However, in select cases, this technique may involve unnecessary resection of sinonasal structures. In this study, we propose a modification of the EMLP, termed the modified subtotal-Lothrop procedure (MSLP), to access the anterior skull base and complex frontal sinus disease for which access to the bilateral frontal sinus posterior table is required. Methods A cadaveric dissection with photo documentation was performed at an academic medical center on four cadaver heads using standard endoscopic techniques to demonstrate the MSLP and its feasibility. Results The endoscopic MSLP allowed ample access for instrumentation in each of the dissections using a 30- or 70-degree endoscope. Adequate bilateral access to the posterior table of the frontal sinus was gained in all cases without the need for dissection of the contralateral frontal sinus recess (FSR). Conclusion The MSLP appears to be a feasible technique for exposure of the anterior skull base and accessing complex frontal sinus pathology. This modification provides similar anterior skull base exposure and surgical maneuverability as the EMLP while limiting surgical dissection to one FSR, thereby preserving as much of the natural mucociliary drainage pathways as possible.

High-resolution computed tomography analysis of the frontal sinus ostium: a pilot study

PURPOSE

Identification and exposure of the frontal sinus recess (FSR) during endoscopic sinus surgery (ESS) are challenging due to the variable anatomy, the narrow opening of the frontal sinus ostium (FSO), and the proximity of vital anatomic structures. Hence, a strong understanding of frontal sinus anatomy is required to prevent intracranial entry. Consistent and easily identifiable landmarks and measurements could assist safe entry into the FSO. In this study, we determine the distances from the columella and anterior nasal spine (ANS) to the nasofrontal beak (NFB) and anterior skull base (ASB) using high-resolution computed tomography (HRCT) scans.

METHODS

A radiographic analysis was performed at a tertiary care medical center. Measurements from the ANS to the NFB and ASB, and from the columella to the NFB and ASB were made using sagittal HRCT. Thirty-two HRCT scans were analyzed by three observers, and the mean distances and standard deviations were calculated.

RESULTS

The mean distance from the ANS to the NFB was 52.3±3.4mm in men and 47.7±3.5mm in women (p<0.0001). Mean distance from the ANS to the ASB was 61.8±4.1mm in men and 56.5±4.1mm in women (p<0.0001). Mean distance from the columella to the NFB was 58.9±2.3mm in men and 53.0±3.3mm in women (p<0.0001), and from the columella to the ASB was 67.9±3.7 mm in men and 61.3±4.1mm in women (p<0.0001).

CONCLUSION

While performing FSR exposure in ESS, it is recommended to stay a distance of less than 66.9 mm in men and 60.6mm in women from the columella to minimize intracranial complications.

Pan-American Clinical Guideline on Rhinosinusitis

Objective: This evidence-based clinical practice guideline (CPG) aims to improve clinical decision making of general practitioners and specialists in the treatment of acute and chronic rhinosinusitis in adults. Support clinicians in clinical decision making for medical treatment with target in the pathophysiological process and evidence-based efficacy, safety, and tolerability.

Method: The Pan-American Association of Otorhinolaryngology and Head and Neck Surgery, in partnership with the Ibero American Agency for Development and Assessment of Health Technologies, developed a clinical practice guideline on medical management of acute and chronic rhinosinusitis in adults. This document provides punctual evidence-based recommendations for primary care physicians and otolaryngologists on the medical management of these conditions and complies with evidence-based medicine fundamentals and with well-validated guidelines methodology as recommended by the National Institute for Clinical Excellence, the National Institutes of Health, and The Scottish Intercollegiate Guidelines Network.

Results: This document provides from A Grade to D Grade clinical recommendations for treatment of these conditions. The Guideline Development Group made recommendations based on well-designed, randomized controlled trials and systematic reviews. Some clinical questions could not be answered by high quality research and for these questions a Panel Delphi was conducted to provide clinical guidance. Overall there is a need for well-designed RCTs and economic assessments to answer most of the gaps of knowledge for the treatment of acute and chronic rhinosinusitis.

Conclusion: This clinical practice guideline provides guidance for the medical treatment of adults with acute and chronic rhinosinusitis.

Inverted papillomas and benign nonneoplastic lesions of the nasal cavity

BACKGROUND

Benign lesions of the nasal cavity represent a diverse group of pathologies. Furthermore, each of these disorders may present differently in any given patient as pain and discomfort, epistaxis, headaches, vision changes, or nasal obstruction. Although these nasal masses are benign, many of them have a significant capacity for local tissue destruction and symptomatology secondary to this destruction. Advances in office-based endoscopic nasendoscopy have equipped the otolaryngologist with a safe, inexpensive, and rapid means of directly visualizing lesions within the nasal cavity and the initiation of appropriate treatment.

METHODS

The purpose of this study is to review the diagnosis, management, and controversies of many of the most common benign lesions of the nasal cavity encountered by the primary care physician or otolaryngologist.

RESULTS

This includes discussion of inverted papilloma (IP), juvenile angiofibroma, squamous papilloma, pyogenic granuloma, hereditary hemorrhagic telangiectasia, schwannoma, benign fibro-osseous lesions, and other benign lesions of the nasal cavity, with particular emphasis on IP and juvenile angiofibroma.

CONCLUSION

A diverse array of benign lesions occur within the nasal cavity and paranasal cavities. Despite their inability to metastasize, many of these lesions have significant capability for local tissue destruction and recurrence.

Initial Dosing of Botox A in Adductor Spasmodic Dysphonia

Objective: 1) Assess effect on voice improvement and duration of breathiness based on initial dose of BotoxA in management of adductor spasmodic dysphonia. 2) Compare voice outcomes for initial bilaterally injected doses of 1.25 units Botox A (Group A) versus 2.5 units (Group B).

Method: A retrospective chart review was undertaken of all adductor spasmodic dysphonia patients treated at a tertiary care facility between 1990 and 2011. Demographic data (age and sex), voice rating, duration of voice improvement, and breathiness were evaluated and compared between Groups A and B using Student’s t test and chi-square analysis.

Results: Of 478 patients identified, 305 (group A: 223; group B: 82) patients met inclusion criteria. The average age of group A was 56.2 years and group B was 57.4 years ( P = .5). The female/male ratio was 2.91 for group A versus 3.56 for group B ( P = .61). Good voice outcomes (grade 3 or 4) were reported by 91% of group A patients versus 94% of group B ( P = .75). The average duration of voice improvement was 99.7 days for group A and 108.3 for group B ( P = .54). The average duration of breathiness was 10.88 days for group A versus 15.42 for group B ( P = .02).

Conclusion: Patients injected with 1.25 units bilaterally had a statistically significant shorter duration period of breathiness without a statistically significant difference in clinical effectiveness or voice outcome. It is therefore recommended that a relatively low initial Botox dose be used with subsequent titration to achieve improved voice outcomes.

Primary sclerosing fibroinflammatory pseudotumor of the maxillary sinus

Inflammatory pseudotumor is a well known but poorly understood pathologic entity. It is associated with an unusual growth of fibrotic tissue admixed with varying amounts of inflammation that displaces and compresses normal anatomic structures, resulting in dysfunction. Pseudotumors have been found in multiple locations-the orbit in particular-but to the best of our knowledge, none has previously been reported as an isolated sinus lesion. We describe a case of primary sclerosing fibroinflammatory pseudotumor of the maxillary sinus that manifested as recurrent unilateral maxillary sinusitis in a 47-year-old woman. The patient was managed with surgery and oral steroids with full resolution of her symptoms. We also review the presentation, diagnosis, and treatment of fibroinflammatory pseudotumors within the context of the current literature.

Feasibility of in-office endoscopic sinus surgery with balloon sinus dilation

BACKGROUND

Balloon sinus dilation (BSD) tools are increasingly used in endoscopic sinus surgery (ESS) and post maximal may cause less tissue trauma/bleeding, potentially enabling office-based ESS. We evaluate the feasibility of ESS performed in-office using BSD instrumentation.

METHODS

All patients had a diagnosis with chronic rhinosinusitis. Because of symptom resolution failure postmaximal medical therapy (prolonged antibiotics, corticosteroids, and other adjuvant therapies), all patients were candidates for ESS. In-office ESS using BSD tools was performed on 37 subjects at nine sites. Procedure feasibility was assessed prospectively through technical success rate, procedure tolerability, quality of life, and radiographic outcomes. Subjects were followed at 1, 4, 24, and 52 weeks.

RESULTS

In-office technical success by subject was 89% (33/37). There was one nonserious adverse event. In-office BSD was tolerable, with 93% (27/29) of patients reporting the procedure as tolerable or highly tolerable. Two in-office subjects (7%) indicated poor procedure tolerability. Intraprocedure pain was also well managed during in-office BSD, with 66% (24/36) of patients reporting no pain or pain of low intensity. While 33% (12/36) reported higher-scale pain, usually during balloon inflation, only 2 patients experienced intense pain. At 52 weeks, 95% of the subjects stated they would have procedure again. Sino-Nasal Outcome Test-20 scores revealed clinically and statistically significant treatment effects at all time points, comparable to previous balloon dilation studies conducted in an operating room setting. Lund-Mackay scores revealed a statistically significant reduction at 24 weeks.

CONCLUSION

Office-based ESS with BSD is feasible with demonstration of high technical success rate, meaningful patient symptom improvement, and high patient satisfaction.

High-resolution computed tomography analysis of the medial infratemporal fossa: a pilot study

BACKGROUND

The medial aspect of the infratemporal fossa (ITF) can be accessed endoscopically. Two important landmarks to help guide dissection in this area have previously been identified: the anterior border of the foramen ovale (AFO) and the "bony bridge" (BB), a consistent bridge of bone between the foramen ovale and spinosum. We conducted a pilot study using high-resolution computed tomography (HRCT) to measure the distances to these structures.

METHODS

Thirty measurements were acquired from 15 adult patients undergoing HRCT scans of the sinuses. The position of the anterior nasal spine (ANS), AFO, and BB on the 3 orthogonal planes were identified by 3 observers. Euclidian distances between each of these structures were calculated. A cadaveric dissection was performed and images were acquired to provide an endoscopic view.

RESULTS

Fifteen HRCT scans of the sinuses (8 females) were analyzed. The mean distances from the ANS to the AFO and BB were 78.5 ± 5.9 mm and 83.2 ± 6.0 mm, respectively. For males alone, these distances were 80.3 ± 4.3 mm and 85.3 ± 4.8 mm, respectively, and in females 77.0 ± 6.5 mm and 81.4 ± 6.7 mm, respectively.

CONCLUSION

Average distance from the ANS to the AFO and BB was 78.5 mm and 83.2 mm, respectively. These measurements can be used by endoscopic skull base surgeons to guide dissection in the ITF.

Endoscopic Management of Sinonasal Hemangiopericytoma

Objective. Sinonasal hemangiopericytomas (SNHPCs) are rare perivascular tumors with low-grade malignant potential. Traditionally, these tumors have been treated with open approaches such as lateral rhinotomy, Caldwell-Luc, or transfacial approaches. Increased experience with endoscopic management of benign and malignant sinonasal tumors has led to a shift in management of SNHPC. The authors present their experience in the largest series of patients with SNHPC managed endoscopically.

Study Design and Setting. Case series at a tertiary care medical center.

Subjects and Method. A retrospective chart review of all patients undergoing endoscopic management of SNHPC at the University of Miami between 1999 and 2008 was conducted. All endoscopic resections were performed with curative intent.

Results. Twelve patients with the diagnosis of SNHPC were treated endoscopically. Mean age was 62.5 years (range, 51-83 years). There were 6 men and 6 women. The mean follow-up was 41 months (range, 15-91 months). Seven (58.3%) presented with nasal obstruction, whereas 4 (41.6%) had epistaxis as their initial presenting symptom. Preoperative angiography or embolization was not performed in any case. Mean estimated blood loss was 630 mL (range, 100-1500 mL). Six patients underwent endonasal endoscopic anterior skull base resection; 4 had complete endoscopic resection all with negative margins. None underwent postoperative adjuvant treatment. No recurrence or metastatic disease was observed in this patient population.

Conclusion. Endoscopic management of SNHPC is a feasible approach and did not compromise outcomes in this experience. In this series, familiarity with advance endoscopic sinus surgery was necessary to manage these patients. Postoperative adjuvant therapy was not necessary in this cohort.

Case report: Liposarcoma of the sinonasal tract

Nasal and paranasal malignant tumours account for less than 5% of all head and neck malignancies. Epithelial malignancies overwhelmingly predominate, with squamous cell carcinomas representing the most frequent histological subtype in this location. Soft-tissue sarcomas of the nasal cavity and paranasal sinuses are exceedingly rare. Here, we report two cases of myxoid liposarcomas that occurred in the nasal and paranasal regions, both of which presented diagnostic challenges and could not be diagnosed definitively from intraoperative frozen sections. These cases reinforce the notion that, while they are uncommon, sarcomas in general and liposarcomas in particular should still be considered as part of the differential diagnosis in patients presenting with obstructive symptoms in the nasal and paranasal sinuses.

Effect of coblation polypectomy on estimated blood loss in endoscopic sinus surgery

BACKGROUND

We conducted a pilot study comparing estimated blood loss (EBL) using coblation-assisted endoscopic sinus surgery (CAESS) where coblation is used to debulk nasal polyps before microdebridement with a traditional microdebrider technique in chronic rhinosinusitis (CRS) patients with sinonasal polyps undergoing endoscopic sinus surgery (ESS).

METHODS

A retrospective analysis was performed at a tertiary care center on patients with nasal polyposis undergoing ESS between January 2008 and July 2008. The University of Miami CT staging system was used preoperatively to evaluate the extent of sinonasal disease. The duration of surgery, blood loss per minute, total EBL, and demographic data were collected.

RESULTS

Twenty-one patients underwent nasal polypectomy/ESS using CAESS and 16 patients underwent nasal polypectomy/ESS using microdebridement. The two groups had comparable University of Miami CT staging scores (p>0.05). The average EBL was 307.1+/-169.8 mL using coblation compared with 627.8+/-424.2 mL using microdebridement (p<0.05). The average duration of surgery using coblation was 116.2+/-41.7 minutes, compared with 125.3+/-48.4 minutes using microdebridement (p>0.05). The average blood loss per minute was 2.8+/-1.7 mL in the coblation group compared with 4.8+/-2.1 mL in the microdebridement group (p<0.05). Subgroup analyses showed a significant decrease in average EBL and EBL/minute to be only significant for revision cases (p<0.05) and not for primary cases (p>0.05).

CONCLUSION

Coblation-assisted nasal polypectomy/ESS is associated with a statistically significant lower EBL and blood loss per minute when compared with traditional microdebridement technique. Coblation represents a new device that can reduce blood loss in patients with nasal polyposis undergoing traditional revision ESS. Further prospective randomized trials are needed to validate these findings.

Endoscopic transnasal study of the infratemporal fossa: a new orientation

INTRODUCTION

The medial portion of the infratemporal fossa (ITF) is not infrequently involved in sinonasal and skull base pathologies. However, endoscopic view of the ITF remains unclear with lack of studies addressing this region from the endoscopic perspective.

METHODS

Using an extended endoscopic approach, the pterygopalatine and infratemporal fossae were dissected in 10 sides of five adult cadaver heads. A plane of dissection along the pterygoid base and the infratemporal surface of the greater sphenoid wing was developed. High-quality images were produced by coupling the video camera to a digital recording system.

RESULTS

The foramen rotundum, ovale, and spinosum were accessed and new landmarks were described from the endoscopic point of view. The sphenomandibularis muscle was also highlighted. Maxillary and mandibular nerves and middle meningeal artery were all identified. Columellar measurements to the foramen rotundum and ovale ranged from 6.1 to 8.0 cm for the former and 7.0 to 9.1 cm for the latter, with a mean of 6.75 cm and 7.78 cm respectively.

CONCLUSION

The current study provides a novel endoscopic orientation to the medial ITF. Such knowledge should provide an anatomical basis for experienced surgeons to endoscopically address this region with more safety and efficacy.