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Background: Middle meatal antrostomy (MMA) is the traditional intervention for chronic maxillary sinusitis but often fails to correct a nonfunctioning maxillary sinus that has lost its capability for mucociliary clearance. Endoscopic-modified medial maxillectomy (EMMM) can reshape the maxillary sinus and avoid a "sumping" effect, preventing secondary bacterial colonization, encouraging dependent drainage, and promoting effective nasal irrigation. Objectives: We describe a modification of the EMMM surgical technique in patients with recalcitrant maxillary sinusitis and perioperative outcomes. Methods: Consecutive adult patients with nonfunctioning maxillary sinuses managed with EMMM were assessed. Primary outcomes were the resolution of the presenting symptom and the absence of mucostasis. Secondary outcomes were early (<90 days) and late (>90 days) morbidity. Results: Fifty-seven patients (51.7 ± 17.5 years, 56.1% female) were assessed. Fifty-two patients had complete resolution of their presenting symptom (91.2% [95% CI: 80.7–97.1]) and 52 patients had an absence of mucostasis (91.2% [95% CI: 80.7–97.1]). Those with persistent crusting were also those with symptoms. Early morbidities included temporary dysesthesia (3.2%), bleeding (1.1%), and pain (3.2%), with no late morbidities. Conclusion: EMMM is a robust approach for salvaging a nonfunctioning maxillary sinus. The procedure enhances nasal irrigation, supplants mucociliary clearance, and discourages dependent mucus retention. [ABSTRACT FROM AUTHOR]

Background: A considerable volume of possible applications of artificial intelligence (AI) in the field of rhinology exists, and research in the area is rapidly evolving. Objective: This scoping review aims to provide a brief overview of all current literature on AI in the field of rhinology. Further, it aims to highlight gaps in the literature for future rhinology researchers. Methods: OVID MEDLINE (1946-2022) and EMBASE (1974-2022) were searched from January 1, 2017 until May 14, 2022 to identify all relevant articles. The Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews checklist was used to guide the review. Results: A total of 2420 results were identified of which 62 met the eligibility criteria. A further 17 articles were included through bibliography searching, for a total of 79 articles on AI in rhinology. Each year resulted in an increase in the number of publications, from 3 articles published in 2017 to 31 articles published in 2021. Articles were produced by authors from 22 countries with a relative majority coming from the USA (19%), China (19%), and South Korea (13%). Articles were placed into 1 of 5 categories: phenotyping/endotyping (n = 12), radiological diagnostics (n = 42), prognostication (n = 10), non-radiological diagnostics (n = 7), surgical assessment/planning (n = 8). Diagnostic or prognostic utility of the AI algorithms were rated as excellent (n = 29), very good (n = 25), good (n = 7), sufficient (n = 1), bad (n = 2), or was not reported/not applicable (n = 15). Conclusions: AI is experiencing an increasingly significant role in rhinology research. Articles are showing high rates of diagnostic accuracy and are being published at an almost exponential rate around the world. Utilizing AI in radiological diagnosis was the most published topic of research, however, AI in rhinology is still in its infancy and there are several topics yet to be thoroughly explored. [ABSTRACT FROM AUTHOR]

Background: Central compartment atopic disease (CCAD) and eosinophilic chronic rhinosinusitis (eCRS) are two clinical phenotypes of primary diffuse type 2 chronic rhinosinusitis (CRS) defined in the European Position Paper on Rhinosinusitis 2020 classification. Currently, the distinction between these subtypes relies on phenotypic features alone. Objective: This study aimed to investigate whether eosinophil activation differed between CCAD and eCRS. Methods: A cross-sectional study was conducted of adult patients presenting with CCAD and eCRS who had undergone functional endoscopic sinus surgery. Routine pathology results were obtained from clinical records. Eosinophils were counted on haematoxylin and eosin-stained formalin-fixed paraffin-embedded sinonasal tissue. Eotaxin-3, eosinophil peroxidase and immunoglobulin E levels were assessed using immunohistochemistry. Results: 38 participants were included (51.7 ± 15.6 years, 47.4% female), of whom 36.8% were diagnosed with CCAD and 63.2% with eCRS. The eCRS group was characterised by older age (55.8 ± 16.3 vs 44.5 ± 11.8 years, p = 0.029), and on histology exhibited a higher degree of tissue inflammation (τ b = 0.409, p = 0.011), greater proportion of patients with >100 eosinophils/high power field (87.5% vs 50%, p = 0.011), and higher absolute tissue eosinophil count (2141 ± 1947 vs 746 ± 519 cells/mm2, p = 0.013). Eotaxin-3 scores were higher in the eCRS group (5.00[5.00–6.00] vs 6.00[6.00–6.75], p = 0.015). Other outcomes were similar. Conclusions: Eosinophil and eotaxin-3 levels were elevated in eCRS compared with CCAD, suggesting a greater degree of eosinophil stimulation and chemotaxis. Patients with CCAD were younger. Future investigation and biomarkers may better distinguish CRS subpopulations. [ABSTRACT FROM AUTHOR]

Background: Access to the anterior, lateral, inferior, and inferomedial maxillary sinus has been a limitation of the middle meatal antrostomy. Expanded techniques such as the modified medial maxillectomy provide access to many of these areas but require remucosalization, and crusting can occur during the recovery phase. The prelacrimal approach (PLA) offers direct 0° endoscope access to these areas. Additionally, PLA can preserve the nasolacrimal duct and mucosal coverage. Objectives: We describe the current surgical technique and outcomes of PLA patients. Methods: Consecutive adult patients with pathology addressed by PLA to the maxillary sinus were assessed. The primary outcome was the restoration of the lateral wall, and the secondary outcomes were early (< 90 days) and late morbidity (> 90 days). Results: Forty patients (52.8 ± 17 years, 62.5% female) were assessed. All patients had successful restoration of the lateral nasal wall (100% [95CI: 91.2%-100%]). The complications reported were primarily dysesthesia (early 10% and late 2.5%). Conclusion: The PLA provides robust access to the anterior, lateral, inferior, and inferomedial maxilla. PLA offers rapid mucosal recovery while preserving the normal physiology and the lacrimal systems with low morbidity. [ABSTRACT FROM AUTHOR]

Background: Biologic therapies such as mepolizumab and benralizumab are currently utilised in the treatment of eosinophilic asthma, and are emerging in the management of eosinophilic chronic rhinosinusitis (eCRS). These biologics inhibit the interaction of IL-5 with its receptor, thus impairing cytokine signalling and eosinophil inflammation. Mepolizumab does so by targeting IL-5, whereas benralizumab targets the α chain of the IL-5 receptor. This study compares the sinonasal tissue response to anti-IL-5 biologic therapies in patients with eCRS. Methods: A cross-sectional study of adult eCRS patients who had completed at least 2 cycles of biologic therapy and underwent endoscopic sinus surgery as part of their management were included. Sinonasal mucosal tissue biopsies were obtained intraoperatively and assessed with structured histopathological examination. Comparisons of tissue histopathology outcomes following treatment with mepolizumab or benralizumab were performed. Results: 18 patients (age 49.6 ± 14.2 years, 47% female, 100% co-morbid asthma) were included in this study, comprising 10 patients managed with mepolizumab and 8 patients managed with benralizumab. Even after mepolizumab, the tissue had predominantly eosinophilic inflammation compared to benralizumab (90% v 0%, p < 0.01), which demonstrated a greater lymphoplasmacytic inflammation (10% v 75%, χ2(2) = 14.53, p < 0.01). Compared with benralizumab, mepolizumab had increased tissue eosinophil count (100% v 37.5% >10 eosinophils/HPF, τb = −8.47, p < 0.001) and more severe subepithelial oedema (80% v 37.5% severe, τb = −2.37, p = 0.02). Conclusion: Tissue histopathologic outcomes reflect the differing mechanism of action of mepolizumab and benralizumab in eCRS. Further analysis at the tissue level will provide further information to guide application of mAbs in type 2 inflammatory diseases. [ABSTRACT FROM AUTHOR]

Background: Surgical approaches to the pituitary have undergone significant changes from transcranial, sublabial, direct transnasal microscopic, and now endoscopic. This study compares sinonasal outcomes from patients from these techniques. Methods: A cross-sectional study of patients who underwent pituitary surgery in a tertiary setting was conducted. Patients were recruited via phone, mail, e-mail, and in person. Surveys with questions on nasal function, subsequent nasal treatment, the Nasal Symptom Score (NSS), Sinonasal Outcome Test-22 (SNOT-22), Chronic Sinusitis Survey (CSS), and Short Form 36 version 2 (SF-36v2) were obtained. Results: A total of 252 surveys were sent, of which 165 were returned (65.48% response rate) and 16 were excluded (3 records destroyed, 13 transcranial approach). A total of 149 patients (age 60.10 ± 13.99 years, 47.83% female) were assessed with the following breakdown: sublabial (n = 69), transnasal microscopic (n = 28), and endoscopic (n = 52) approaches. Sublabial and transnasal microscopic, compared to endoscopic, had more sinus treatment (30.43%, 39.29%, and 15.38%; P =.05), medication use (28.99%, 32.14%, and 11.54%; P =.04), and new allergy symptoms (21.74%, 7.14%, and 1.92%; P <.01). Compared to sublabial and transnasal microscopic, endoscopic patients had superior NSSs (0.40 [1.00], 0.60 [1.75], and 0.20 [0.60]; P =.05), SNOT-22 total scores (1.02 ± 0.58, 1.40 ± 0.78, and 1.00 ± 0.59; P <.01), and CSS medication subscores (100.00 [8.33], 100.00 [8.33], and 100.00 [0.00]; P =.03). Endoscopic patients also reported superior SF-36v2 physical subscores (44.02 ± 11.14, 41.13 ± 9.86, and 47.60 ± 10.12; P =.03). Conclusion: Nasal function was superior, and further sinus therapy and medication use was lower in patients with endoscopic approaches. Disease-specific quality of life was superior and the endoscopic approach resulted in reduced long-term sinonasal morbidity. [ABSTRACT FROM AUTHOR]

Background: Nasal irrigation is a significant component of effective medical management in patients with chronic rhinosinusitis (CRS). Irrigations facilitate distribution of topical medical therapies to affected mucosal surfaces and lavage of hypersecretory mucin and inflammatory products. Objective: To compare the effectiveness of cadaveric nasal irrigation distribution and force following different surgical techniques commonly used to open the maxillary sinus. Methods: Fresh human cadaver heads were dissected sequentially with uncinectomy, maxillary antrostomy, endoscopic maxillary mega-antrostomy, and modified endoscopic medial maxillectomy. After each surgical technique was performed, the corresponding nasal cavity was irrigated with 240 mL irrigation bottles containing 1/1000 10% fluroscein-labeled free water. A nasal endoscope passed through the canine fossa into a fixed position in the maxillary sinus recorded the extent of sinus irrigation. These videos then underwent blinded assessment by 2 observers assessing for irrigation sinus penetration (scored as 0–4) and force (0–2). Ordinal correlation scores were assessed using Kendall's tau-B. Results: A total of 17 sinuses (age 53.4 ± 12.6, 36.4% female) were assessed. There was a statistically significant positive correlation between increasing extent of maxillary sinus dissection and both sinus penetration and force as assessed by both observers (Kendall's tau-B P <.0001). Conclusion: Increasing the extent of surgical dissection appears to improve penetration and force of the nasal irrigation into the maxillary sinus. This study suggests that while a standard maxillary antrostomy may be sufficient to achieve good topical therapy distribution, more extensive surgery such as a modified medial maxillectomy may be required for sufficient force of sinus lavage. [ABSTRACT FROM AUTHOR]

Background: Evidence suggests that intrinsic cell dysfunction leads to dysregulated immune responses to environmental triggers in chronic rhinosinusitis (CRS). Although epidemiological and in vivo studies support this theory, in vitro studies are lacking. Methods: Epithelial cells from human sinonasal mucosa were cultured using an air–liquid interface culture model producing a well-differentiated phenotype. Specimens were characterized as chronic rhinosinusitis with (CRSwNP) or without (CRSsNP) nasal polyps and healthy control mucosa. Culture wells were exposed to house dust mite (HDM), diesel exhaust particles (DPM), or a combination (HDM + DPM) over 24 hours and responses in the 3 groups compared. Ciliary beat frequency (CBF) and transepithelial electrical resistance (TEER) were measured to assess mucociliary and barrier function, respectively. Interleukin-6 (IL-6) and 33 (IL-33) were measured after 24 hours. Results following challenge testing are expressed as fold change from baseline. Results: Baseline CBF was lower in CRSsNP compared with control (5.27 ± 0.51 Hz vs 5.88 ± 1.22 Hz, P =.003). HDM significantly reduced CBF and TEER in the CRSwNP group compared with its vehicle (CBF: 0.55 ± 0.25 vs 1.03 ± 0.22, P <.001; TEER: 0.54 [0.13] Ω cm2 vs 0.93 [0.5] Ω cm2, P =.001). In CRSwNP and CRSsNP, HDM induced an increase in IL-6 compared with its vehicle (CRSwNP: 81.11 [67.19] pg/mL vs 3.15 [44.64] pg/mL, P =.016; CRSsNP: 321.46 [182.04] pg/mL vs 21.54 [53.93] pg/mL, P =.004). Results are expressed as median (interquartile range) and in IL-33 in CRswNP (84.04 [69.96] pg/mL vs 16.62 [20.19] pg/mL, P =.025). Exposure to DPM did not affect CBF, TEER, and cytokine release in all groups. Conclusion: CRSwNP and CRSsNP cells exhibit altered responses particularly to HDM even after they have been removed from their host and cultured in vitro, suggesting an intrinsic cell dysfunction of the upper airway epithelium. [ABSTRACT FROM AUTHOR]

Background: Nasal septal perforation repair remains a challenge with no standard technique for repair recognized. Objective: To describe the combination of an anterior ethmoidal artery flap with a collagen matrix inlay as a successful technique for nasal septal perforation repair. Methods: A case series of consecutive patients who underwent nasal septal perforation repair with an anterior ethmoidal artery flap with an inlay collagen graft was conducted. Demographic data, preoperative features of the perforation (size, location, and presence of chondritis), and postoperative outcomes were analyzed; closure rate, mucosalization rate (of the contralateral side at 21 and 90 days), and complications (crusting, bleeding, obstruction, infection, and rehospitalization <30 days) were documented. Results: Thirteen patients (age: 49 ± 15 years, 30.8% women) were assessed. The perforation size was 1.6 ± 0.9 cm (range: 0.3–3.5 cm) and located 1.2 ± 0.5 cm (range: 0.5–2.0 cm) posterior to the columella. Chondritis was present in 69.2%. The closure rate was 100% (95% confidence interval [CI]: 77%–100%) at both 21 and 90 days. One patient required a free mucosa graft to an area of persistent crusting on the contralateral side (7.7%). Complications were low; bleeding 0%, obstruction 7.7% (requiring corticosteroid injection of anterior ethmoidal artery flap), and 0% infection/rehospitalization. Conclusion: Anterior ethmoidal artery flap with an inlay collagen matrix is a reliable technique to repair nasal septal perforation. This technique, with robust vascularity and wide angle of rotation, enables the closure of perforations both large (<50% total septum) and with anterior locations. [ABSTRACT FROM AUTHOR]

Background Specific immunoglobulin E (sIgE) within the nasal airway is likely to be the most ideal marker of allergic status, but little is known of the normative values in asymptomatic patients and those with rhinitis. Objective The aim of this study was to assess the diagnostic characteristics of inferior turbinate tissue biopsy sIgE in asymptomatic and rhinitic patients. Methods A diagnostic cross-sectional study was undertaken, involving patients who underwent inferior turbinate surgery with or without other surgical interventions. Inferior turbinate tissue biopsy was performed during surgery and was assessed for allergen sIgE (dust mite, grass [temperate or subtropical], and animal epithelium) using an automated immunoassay. Tissue sIgE was assessed among asymptomatic patients and those with nasal symptoms. Data were presented as median (interquartile range). A receiver operating curve was used to predict the diagnostic utility of turbinate tissue sIgE in determining allergic rhinitis. Results A total of 160 patients (41.89 ± 14.65 years, 36.9% females) were included. The median tissue sIgE concentration among the asymptomatic nonatopic group of patients was 0.09 (0.08–0.10) kUA/L and tissue sIgE > 0.10 kUA/L was determined as a positive threshold. Inferior turbinate tissue sIgE was shown to be a predictive test for allergic rhinitis (area under curve: 0.87, 95% confidence interval: 0.84–0.90) with 90% sensitivity and 89% negative predictive value. Conclusion Inferior turbinate tissue biopsy sIgE is a sensitive tool to predict allergic rhinitis. The threshold value of 0.1 kUA/L corresponded well with the asymptomatic nonatopic group of patients. This method detects sIgE in the nasal mucosa and may be a useful test for allergic rhinitis in future research. [ABSTRACT FROM AUTHOR]

Background Eosinophilic chronic rhinosinusitis (eCRS) is linked with skewed T-helper 2 or immunoglobulin E (IgE)-mediated allergic responses, with differing diagnosis, prognosis, and management to non-eCRS. Objective The association between biomarkers and eCRS was investigated to assess the predictors of eCRS. Methods A cross-sectional study of adult patients with chronic rhinosinusitis (CRS) undergoing endoscopic sinus surgery was conducted. eCRS was defined by histopathological assessment showing >10 eosinophils/high-power field on sinus mucosal biopsy. Blood tests were performed preoperatively and assessed for a full blood count including eosinophils and a white cell count (WCC) as well as biochemical markers of inflammation and atopy including Immunoglobulin E (IgE), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and ImmunoCAP testing for serum-specific IgE. Comparisons between eCRS and non-eCRS patients were performed. Results 345 patients (48.1% female, age 48.72 ± 15.06 years) were recruited, with 206 (59.7%) identified as eCRS, 41% with asthma and 47% CRS with nasal polyps. eCRS patients were more likely to have asthma (P < .01) and nasal polyps (P < .01). Blood eosinophils were significantly elevated in eCRS (0.42±0.34 vs 0.17±0.13 × 109/L, P < .01) as were eosinophils as a ratio of WCC (6.21 ± 4.48 vs 2.55 ± 1.84, P < .01). ESR was decreased when compared with non-eCRS (8.1±7.87 vs 10.65±11.91, P = .03). Receiver operating characteristic curve analysis predicted high tissue eosinophilia at blood eosinophil levels above 0.24 × 109/L (sensitivity 70.9%, specificity 78.4%, area under the curve [AUC]: 0.792, P < .01). eCRS was predicted at eosinophil above 4.27% of total WCC (sensitivity 64.1%, specificity 88.5%, AUC 0.797; P < .01; positive predictive value 89.2%, negative predictive value 62.4%, positive likelihood ratio 5.57, and diagnostic odds ratio 13.71). There was no significant association among WCC, CRP, IgE, or ImmunoCAP testing. Conclusion eCRS is associated with elevated blood eosinophils (>0.24 × 109/L), eosinophil ratio (>4.27% of total WCC), and lower ESR when compared with non-eCRS. [ABSTRACT FROM AUTHOR]

Background: Isolated polypoid changes of the middle turbinate were recently reported as having a high association with inhalant allergy. A more advanced manifestation of this association may present as polypoid changes of the entire central sinonasal compartment (i.e., the middle and superior turbinates, and the posterosuperior nasal septum), while the lateral sinus mucosa remains relatively normal. Objective: To introduce and describe this newly recognized variant of chronic rhinosinusitis (CRS), termed central compartment atopic disease (CCAD). Methods: A case series of 15 patients from two institutions who presented with sinonasal symptoms and demonstrated central compartment polypoid mucosal changes on computed tomography (CT). The endoscopic appearance of central compartment edema was assessed. Allergy status was determined by skin or serum in vitro testing. Results: The mean ± standard deviation patient age was 42.4 ± 14.8 years, and 47% of the patients were women. All 15 patients had a diagnosis of allergic rhinitis symptomatically, and those who underwent allergy assessment (14/15) tested positive. All the patients had central compartment polypoid edema on endoscopy and central nasal soft-tissue thickening with peripheral clearing on CT. Even with more severe sinus disease, a central focus of inflammatory change existed. Conclusion: CCAD may represent a local inhalant allergy process that affects the central nasal structures of ethmoid origin. Although inhalant allergy changes mainly appear within the nasal cavity, medial-to-lateral progression to involve the sinuses can occur as a simple obstructive phenomenon. This is a pattern of CRS distinct from the more diffuse sinonasal inflammatory disease and likely requires allergy management as a core component. [ABSTRACT FROM AUTHOR]

Background: Chronic rhinosinusitis (CRS) has a multifactorial etiology, with a debate about the role of inhalant allergy in the pathogenesis of CRS. Objective: This study assessed the impact of allergy status on externalized paranasal sinuses after tumor resection to determine if a predisposition to inhalant allergy brought about additional inflammation after sinus surgery. Methodology: A case-control study was performed on patients who had no history of CRS who underwent paranasal sinus tumor resection. Allergic sensitization was defined by a positive serum ImmunoCAP test result. Outcomes were measured at least 6 months after surgery by using the modified Lund-MacKay endoscopic score and the 22-item Sino-Nasal Outcome test, with rhinitis, sleep, psychological, ear and/or facial, and sinus subscores to assess the impact of allergy status on mucosal inflammation. Results: A total of 103 patients (53.44 ± 17.46 years; 46% women) were assessed. Of these, 61.17% were allergically sensitized at the time of surgery. Postsurgery endoscopic assessment was similar I the modified Lund-Mackay endoscopic score allergic sensitized 0.5 (1.7) versus nonallergic sensitized 0.0 (0.9); p = 0.15], Sinonasal symptoms were also similar between the groups' 22-item Sino-Nasal Outcome test scores, allergic sensitized versus allergic nonsensitized, (allergic 28.9 ± 20.8 versus nonallergic 33.5 ± 19.7; p = 0.32), rhinitis score (5.9 ± 5.5 versus 6.4 ± 4.7; p = 0.66), sleep score (6.9 ± 5.9 versus 7.7 ± 4.8; p = 0.50), ear and/or facial symptom score (3.4 ± 3.6 versus 4.3 ± 3.3; p = 0.22), psychological score (6.9 ± 6.0 versus 8.3 ± 6.7; p = 0.29), and of nasal symptom score (6.4 ± 5.2 versus 7.0 ± 5.3; p = 0.61). Conclusions: Externalization of the sinuses in patients with inhalant allergy did not bring about significant additional inflammation in patients after tumor surgery. [ABSTRACT FROM AUTHOR]

Background: Retromaxillary air cells (RMC) are posterior ethmoid cells that separate the maxillary and ethmoid sinuses. The clinical significance of these cells in contributing to revision functional endoscopic sinus surgery (FESS) is unknown. Objectives: To investigate the prevalence, anatomic dimensions, and radiographic characteristics of RMC in patients with recalcitrant chronic rhinosinusitis after previous FESS. Methods: A retrospective review of patients who underwent revision FESS at a tertiary medical center between January 1, 2012, and December 31, 2014. Computed tomographies of patients who underwent revision FESS, including posterior ethmoidectomies, were reviewed. Each side of the scan was assessed for residual RMCs. The radiographic dimensions and Lund-Mackay (LM) scores of these cells were recorded. Results: Sixty-nine patients who underwent revision FESS were identified. The median age of the patient population was 51 years (range, 21-79 years). Forty-two percent of the patients had nasal polyps. The mean number of previous FESS was 2 (range, 1-10). Incompletely dissected RMCs were identified in 101 of 138 analyzed sides (73%), despite documented previous posterior ethmoidectomies. Sixty-five percent of RMCs had an LM score of ≥1; RMCs of patients with polyps were more likely to have an LM score of 2 (p = 0.049). There was a significant correlation between the number of previous FESS procedures and whether the RMCs had been dissected (p = 0.010). There also was a significant correlation between RMC height and the number of previous FESS procedures (p = 0.015). Conclusion: RMCs seemed to often be undissected during primary FESS and, thus, were commonly encountered in revision FESS. The majority of analyzed cells in this cohort demonstrated an LM score of ≥1, which indicated that these cells frequently harbor residual diseased mucosa that may contribute to the need for revision surgery. [ABSTRACT FROM AUTHOR]

Background: Clinicians who manage nasal obstruction often comment on the shape and size of the nasal valve (NV) area. However, correlation of the symptoms of obstruction, nasal airflow dynamics, and the endoscopic appearance of the anatomic cross-sectional area of the NV is poorly understood. Endoscopic imaging and calculation of the NV area is investigated as a tool for either clinical or research use. Objective: To describe and evaluate a two-dimensional measurement of the minimum cross-sectional area (MCA) of the NV by using endoscopic imaging. Methods: A cross-sectional study of patients with symptoms of nasal obstruction who were undergoing nasal assessment was performed. The NV was measured with digital imaging taken from the endoscopy. Adobe Photoshop was used to calculate the digital MCA of the NV based on pixel count and a reference marker placed in the image field. Airway parameters were assessed by using a nasal obstruction visual analog scale, nasal airway resistance via rhinomanometry, and acoustic rhinometry derived MCA (acoustic MCA). Correlation of the digital MCA and airway parameters was made and interobserver correlation of the MCA measures was calculated. Results: Thirty-three nasal airways were assessed: mean (standard deviation) digital MCA (0.28 ± 0.13 cm2) and mean (standard deviation) acoustic MCA (0.51 ± 0.15 cm2). Correlation of the digital MCA with visual analog scale was poor (Pearson r = 0.10, p = 0.56). Similar finding between digital and acoustic MCA was poor (Pearson r = 0.50, p = 0.56, respectively) despite a moderately strong interobserver correlation for the digital MCA (Pearson r = 0.79, p < 0.001). Conclusion: Qualitative endoscopic assessment of the NV may help clinicians predict NV dysfunction but simple two-dimensional measures seemed to be of limited value in accurately assessing the three-dimensional NV quantitatively. [ABSTRACT FROM AUTHOR]

Background: Surgical landmarks for defining the level of the skull base during endoscopic sinus and skull base surgery (ESBS), e.g., the middle turbinate, may be distorted by tumor or previous surgery. The orbital floor is a valid fixed anatomic landmark for the white population, but it is not known if its use is useful for an Asian population. Objectives: To define fixed anatomic landmarks for ESBS in an Asian population and to compare the level of the skull base and its relation with anatomic landmarks between Asian and white populations. Methods: Computed tomographies performed on paranasal sinuses of Thai patients were retrospectively assessed. The distance between the nasal floor to four structures, the orbital floor, sphenoid planum, cribriform, and ethmoid roof, were measured. The level of skull base related to the orbital floor of an Asian population was compared with data of a white population from a previously published study. Results: A total of 150 Thai patients (300 paranasal sinus systems) were assessed and compared with 150 white patients. The orbital floor was always below the skull base (600 sides [100%]). When compared with white patients, the Asian patients had significantly higher mean (standard deviation [SD]) values: orbital floor (35.2 ± 3.4 mm versus 33.9 ± 3.0 mm; p < 0.001), ethmoid roof (49.3 ± 3.8 mm versus 48.4 ± 4.5 mm; p = 0.01), cribriform (46.4 ± 3.6 mm versus 44.0 ± 3.7 mm; p < 0.001), and sphenoid roof (45.7 ± 3.7 mm versus 44.9 ± 3.7 mm; p = 0.01). The Asian population had a mean (SD) longer distance from the orbital floor to the cribiform (11.2 ± 2.5 mm versus 10.1 ± 2.7 mm; p < 0.001), a shorter distance to the sphenoid roof (10.5 ± 3.3 mm versus 11.0 ± 2.9 mm; p = 0.03), and a similar distance to the ethmoid roof (14.1 ± 3.1 mm versus 14.5 ± 3.5 mm; p = 0.09). Conclusion: Although a statistical difference exists between racial groups, clinically, the orbital floor is a useful fixed anatomic landmark for ESBS for both Asian and white populations. [ABSTRACT FROM AUTHOR]

Background: The Draf 3 frontal sinusotomy, or modified Lothrop procedure has been used to treat recalcitrant rhinosinusitis, frontal sinus mucocoeles or to provide access for cerebrospinal fluid leaks, frontoethmoid fractures, frontal sinus tumors and skull base tumors. Objective: To describe authors approach to the 'Outside-In Frontal Drill-Out'. Methods: Descriptive. Results: The 'Outside-In' frontal drill-out is an approach that emphasizes the early identification of the first olfactory neuron, maximization of bone removal, and preservation of the posterior table mucosa. Conclusion: The advantages of this approach are it provides unobstructed view and identifies anatomic limits early, bone removal is fast and efficient; it is safe, and it is a robust technique based upon fixed anatomic landmarks. [ABSTRACT FROM AUTHOR]

Background: The initiating mediators of T-helper 2 inflammation, often seen in eosinophillic chronic rhinosinusitis (CRS), remains poorly understood. Interleukin (IL) 25, IL-33, and thymic stromal lymphopoietin (TSLP) are epithelial-derived cytokines implicated in the initiation of T-helper 2 inflammation and eosinophilia in other diseases. The expression of these cytokines was compared with phenotypic and histopathologic markers to investigate the factors that may drive eosinophilic inflammation in CRS. Method: Sinus mucosal samples from patients with CRS who were undergoing sinus surgery as part of their management were analyzed for IL-25, IL-33, and TSLP messenger RNA (mRNA) expression by quantitative polymerase chain reaction. Patients with tumor and who were undergoing surgery via an endonasal approach with normal sinus mucosa were controls. The mRNA expression was compared with CRS phenotype and histopathologic measures of eosinophilic inflammation. Immunohistochemical staining was used to confirm mRNA expression. Results: Thirty-nine patients (mean ± standard deviation age; 48.2 ± 15.0 years, 38% women), 12 patients with CRS with nasal polyps, 20 patients with CRS without nasal polyps, and 7 controls were recruited. Higher IL-25 (p = 0.005) and IL-33 (p = 0.003) mRNA and protein expression was observed in patients with >10 eosinophil/hpf. TSLP showed no significant associations (p = 0.39). Similar overexpression was seen in eosinophilic dominated inflammation (IL-25, p = 0.01; IL-33, p = 0.02) and patients with greater inflammatory severity. Conclusion: IL-25 and IL-33 overexpression was observed in eosinophilic CRS, The release of these cytokines by dysfunctional endothelium may perpetuate the eosinophillic inflammation in CRS. [ABSTRACT FROM AUTHOR]

Background: Intranasal corticosteroids (INCSs) are well established in the treatment of allergic rhinitis, chronic rhinosinusitis, and nasal polyposis. Although reversible atrophy of keratinized skin is seen with corticosteroids, the respiratory mucosa is histologically very different and but concerns remain among patients and some health-care professionals over local side effects on nasal respiratory mucosa. A systematic review and meta-analysis were performed of the available evidence for nasal mucosal atrophy as an adverse effect of INCSs in patients with sinonasal disease. Methods: A systematic search of Embase (1974-) and Medline (1946-) databases to September 27, 2013 was performed. Inclusion criteria selected any study where the histopathology of nasal mucosa was assessed in patients with sinonasal disease using intranasally administered corticosteroids with or without a control group. Results: Twenty-three hundred sixty-four publications were retrieved with a subsequent full text review of 149 publications for 34 articles that met the selection criteria. These articles included 11 randomized controlled trials, 5 cohorts, and 20 case series. Duration of treatment varied from 5 days to 5.5 years. 'Mucosal atrophy' as an outcome was reported in 17 studies. The definition of 'mucosal atrophy' was highly variable with a definition given in only 10 studies. One hundred thirty-six patients were represented in controlled studies of atrophy with only one study reporting the event in both groups with an odds ratio of 'mucosal atrophy' at 0.51 (95% CI, 0.09-3.11; p = 0.47). Conclusion: The concept of nasal mucosal atrophy is poorly defined and there is no histological evidence for deleterious effects from INCS use on human nasal mucosa. [ABSTRACT FROM AUTHOR]

Malignant tumors of the sinonasal tract are uncommon tumors of the head and neck. Patients often present in the later years of life with unilateral symptoms and potential involvement of nearby structures such as the orbit, brain, or cranial nerves. Presenting symptoms are similar to patients suffering from inflammatory sinonasal disease and thus early diagnosis relies heavily on a high clinical suspicion. There are established risk factors based on exposure to the by-products of woodworking, metal, textile, and leather industries. Sinonasal malignancies are generally divided into those of epithelial origin (squamous cell carcinoma, adenocarcinoma, and adenoid cystic carcinoma) and nonepithelial origin (olfactory neuroblastoma, chondrosarcoma, and mucosal melanoma). Accurate histopathology confirmation and staging of the tumor is critical prior to making treatment decisions. Both computed tomography and magnetic resonance imaging are required to accurately determine the extent of local disease. Treatment is based on multimodality therapy, primarily surgical excision, and postoperative radiotherapy. This article reviews the classification of malignant tumors of the paranasal sinuses, their clinical presentation, relevant diagnostic investigations, and the principals of therapy and management. [ABSTRACT FROM AUTHOR]

An understanding of paranasal sinus anatomy based on important fixed landmarks rather than variable anatomy is critical to ensure safe and complete surgery. The concept of the paranasal surgical box defines the anatomic limits of dissection. The boundaries of the surgical box include the middle turbinate medially, orbital wall laterally, and skull base superiorly. The "vertical component" of the surgical box defines the boundaries of the frontal recess and includes the middle turbinate and intersinus septum medially, medial orbital wall and orbital roof laterally, nasofrontal beak anteriorly, and skull base and posterior table of frontal sinus posteriorly. The paranasal sinuses are divided into anterior, posterior, and sphenoidal functional cavities based on their distinct drainage pathways into the nose. The ultimate goal of surgery is to create afunctional sinus cavity. Application of the paranasal surgical box and its vertical component enables the surgeon to view the limits of dissection with a single position of the endoscope. This will ensure complete dissection of the functional sinonasal compartments and effectively avoid leaving behind disconnected cells from the surgical cavity, mucocele formation, mucous recirculation, overcome obstructive phenomenon and enable maximal delivery of topical therapy in the post-operative setting. This article reviews the structure and function of the nasal cartilages and turbinates. It also describes the concept of the paranasal surgical box, key anatomical landmarks and limits of dissection. Normal anatomy and common variants of normal anatomy are discussed. [ABSTRACT FROM AUTHOR]

Background: Published randomized controlled trials (RCTs) on the efficacy of intranasal corticosteroid (INCS) in chronic rhinosinusitis (CRS) use either nasal delivery (nasal drop or nasal spray) or sinus delivery (sinus catheter or sinus irrigation) in patients with or without sinus surgery. This influences topical drug delivery and distribution. The effect of these factors on the published results of RCTs is assessed. This systematic review explores the strength of evidence supporting the influence of sinus surgery and delivery methods on the effectiveness of topical steroids in studies for CRS with meta-analyses. Methods: A systematic review was conducted of RCTs comparing INCS with either placebo or no intervention for treating CRS. Data were extracted for meta-analysis and subgroup analyses by sinus surgery status and topical delivery methods. Results: Forty-eight studies (3961 patients) met the inclusion criteria. INCS improved overall symptoms (standardized mean difference [SMD], -0.49; p < 0.00001) and the proportion of responders (risk ratio [RR], 0.59; p < 0.00001) compared with placebo. It decreased nasal polyp size with a greater proportion of responders (RR, 0.48; p < 0.00001) and prevented polyp recurrence (RR, 0.59; p = 0.0004) compared with placebo. Reduction of polyp size was greater in patients with sinus surgery (RR, 0.31; 95% confidence interval ICI], 0.20, 0.48) than those without (RR, 0.61; 95% CI, 0.46, 0.81; p = 0.009). Greater symptom improvement occurred when sinus delivery methods (SMD, -1.32; 95% CI, -2.26, -0.38) were compared with nasal delivery methods (SMD, -0.38; 95% CI, -0.55, -0.22; p < 0.00001). Conclusion: INCS is effective for CRS. Prior sinus surgery and direct sinus delivery enhance the effectiveness of INCS in CRS. [ABSTRACT FROM AUTHOR]

Background: Chronic rhinosinusitis (CRS) is an inflammatory disorder of the nose and sinuses. Because fungi were postulated as a potential cause of CRS in the late 1990s, contrasting articles have advocated and refuted the use of antifungal agents in its management. Although good research shows an interaction of the immune system with fungus in CRS, e.g., allergic fungal sinusitis (AFS), this does not imply that fungi are the cause of CRS or that antifungals will be effective in management. This study was designed to assess the potential advantage of either topical or systemic antifungal therapy in the symptomatic treatment of CRS to aid physicians in making informed decisions about treating patients with CRS. Methods: A systematic review of the literature was performed with meta-analysis. All studies obtained from searches were reviewed and trials meeting the eligibility criteria were selected. CRS was defined using either the European Position Paper on Rhinosinusitis and Nasal Polyps or American Academy of Otolaryngology-Head and Neck Surgery criteria. Authors were contacted and original data were used for data analysis. Results: Five studies investigating topical antifungals and one investigating systemic antifungals met the inclusion criteria. All trials were double blinded and randomized. Pooled meta-analysis showed no statistically significant benefit of topical or systemic antifungals over placebo. Symptoms scores statistically favored the placebo group for this outcome. Adverse event reporting was higher in the antifungal group. Conclusion: Reported side-effects of antifungal therapies may outweigh any potential benefits of treatment based on this meta-analysis and the authors therefore do not advocate the use antifungal treatment in the management of CRS. [ABSTRACT FROM AUTHOR]

Background: The external approach for septoplasty is an important surgical technique to manage severe septal deviations, caudal deformities, and mid-dorsal abnormalities when a simple endonasal approach may not suffice. The procedure is longer in duration and draws on more resources than endonasal septoplasty. The outcome reporting of the external approach for septoplasty is important to provide evidence of benefit for both patients and health care providers. This study was designed to describe functional and cosmetic outcomes of the external approach for septoplasty. Methods: A prospective assessment of consecutive patients undergoing the external approach for septoplasty at a tertiary center was performed. Pre- and postoperative nasal peak inspiratory flow (NPIF), symptom scores, 22-Item Sinonasal Outcome Test (SNOT-22), Nasal Obstruction Score, and Short Form 36 (SF-36) quality-of-life scores were assessed. A global Likert change scale was also used for both function and cosmesis. Results: Thirty patients (mean age, 40 ± 15.9 years; 40% women) were assessed with a mean follow-up of 12.2 ± 9.5 months. Mean NPIF improved significantly from 93.3 ± 34.7 to 143.0 ± 44.3 (p < 0.001). Nasal obstruction score improved significantly from 3.6 ± 1.3 to 0.69 ± 1.2 (p < 0.001). SNOT-22 improved significantly from 34.1 ± 17.2 to 12.7 ± 14.9 (p < 0.001). Ninety-six percent had subjective improvement in nasal function, and 96% had no change or improvement in cosmesis. Seventy percent improved by the minimal clinically important difference for NPIF. Conclusion: The external approach for septoplasty is an operation that produces significant improvements in subjective and objective nasal health measures. Although requiring greater training and operative time, it is an appropriate approach for the severely deviated nasal septum. [ABSTRACT FROM AUTHOR]

Background: It is generally assumed that all immunoglobulin isotopes develop under antigen selection pressure, leading to dramatic increases in antigen-binding affinity. As activated B cells proliferate, somatic mutations accumulate in the regions of the immunoglobulin gene associated with antigen binding. Emerging evidence from studies investigating mutations in variable region sequences of IgE antibodies suggest that IgE may develop under less selection pressure than other isotypes. Recent studies have focused on IgE mutation patterns in sequences from the blood of allergic individuals. There is, however, little evidence of these patterns in IgE sequences isolated from tissue. Methods: Seminested reverse-transcription polymerase chain reaction was used to amplify the V region of IgE sequences from nasal tissue of individuals with chronic rhinosinusitis with nasal polyps (CRSwNPs). IgE sequences were analyzed for evidence of antigen selection and compared with previously reported IgE sequences from other inflammatory and allergic disorders and nonallergic individuals. Results: IgE sequences were successfully amplified from four individuals with CRSwNPs. Of 217 sequences amplified, 38 were unique, 31 of which were from tissue. Identification of the IGHV, IGHD, and IGHJ genes making up each sequence showed overrepresentation of an unusual gene in one individual, but otherwise normal gene usage. Mutation analysis revealed that only 5 of the 31 unique sequences from tissue show clear evidence of antigen selection. Conclusion: With little influence from antigen selection, IgE antibodies are unlikely to be highly specific for antigens. Consequently, these findings have significant implications for the relevance of specific IgE, e.g., Staphylococcus aureus enterotoxin or fungal-specific IgE, in CRSwNP pathogenesis. Whether specific IgE expression is tightly related to pathogenesis or is merely a byproduct of B-cell interactions in local mucosa with colonizing organisms remains unresolved. [ABSTRACT FROM AUTHOR]

Background: The identification of anatomic landmarks in endoscopic skull base or revision sinus surgery can be challenging. Normal anatomy is significantly altered with many paranasal tumors. Traditional endoscopic surgical landmarks extrapolated from inflammatory disease, such as the superior turbinate, may have been previously removed or involved in pathology. A frequently used rule to enter the sphenoid, “stay below or at the level of the orbital floor as dissection proceeds posteriorly and one will avoid the skull base,” is assessed anatomically. Methods: The maxillary sinus roof height, relative to the nasal floor, was assessed as an operative landmark. Computed tomography (CT) performed on paranasal sinuses was studied. The relative height, ratio, and proportions of the maxillary sinus, ethmoid roof, cribriform fossa, and sphenoid planum were measured using computerized assessments. Results: Three hundred paranasal sinus systems were evaluated. The roof of the maxillary sinus was below the level of the skull base in 100% relative to the cribriform and 100% relative to the sphenoid planum. The mean distance of the maxillary roof below the skull base was 10.1 ± 2.7 mm for the cribriform and 11.0 ± 2.9 mm for the sphenoid. Conclusion: The maxillary sinus roof can be used as a robust landmark to allow safe dissection and debulking of pathology. Pathology removal can proceed posterior with this landmark to enable a safe entry to the sphenoid sinus, and thus the true skull base, when normal structures such as the superior turbinate and ostium are not available. [ABSTRACT FROM AUTHOR]

Background: The complement cascade forms part of the initial innate response to pathogens in the airway. Complement activation is important in the maintenance of host homeostasis, but excessive and uncontrolled activation may lead to inflammation and disease. The role of the complement pathway in the innate response in chronic rhinosinusitis (CRS) is poorly characterized Methods: Sinus mucosa biopsy specimens from the anterior ethmoid or uncinate process of patients with allergic fungal rhinosinusitis (AFRS), CRS without NPs (CRS-NPs), and controls were harvested and gene and protein expression of C3, factor B (fB), C5, and C7 complement proteins were analyzed using quantitative polymerase chain reaction and immunohistochemical techniques. Results: fB, C3, and C5 gene expression were increased in both AFRS and CRS-NPs compared with controls (p < 0.05). Transcriptional activity for the terminal pathway protein C7 was not significantly increased when compared with controls, with C7 levels actually reduced in AFRS patients when compared with controls. Immunohistochemistry studies showed the presence of C3 and fB on the mucosal surface and in submucosa of both AFRS and CRS-NPs, but not normal controls. Terminal pathway protein C9 was not found in our specimens. Conclusion: Both AFRS and CRS-NPs display up-regulation of the complement pathway, in particular, the alternative pathway (fB) and common pathways (C3 and C5). Enhanced innate responses as shown by alterations in complement components may play a pivotal role in the inflammatory response noted in CRS and provide potential therapeutic targets in the future. [ABSTRACT FROM AUTHOR]

Background: Endoscopic skull base reconstruction (ESBR) is an important advance in the management of skull base defects. Large dural defects usually require the use of pedicled mucosal flaps for successful repair and prevention of cerebral spinal fluid leak. Planning for pedicled flaps is important because raising the flap is often required before tumor removal or initial surgical access. The potential utility of the inferior turbinate pedicled flap (ITPF) in ESBR is assessed. Methods: The ITPF was raised in nine cadaver heads. The most anterior extent reached on the anterior cranial fossa (ACF) and inferior limit on the posterior cranial fossa (PCF) were recorded with image-guided surgery. Measurements were calculated as a percentage of ACF or PCF length from easily reproducible measurements from preoperative radiology. The width was defined as the widest measurement in the distal third. The length-to-height ratio of the skull base was also assessed as a confounding factor. Results: Mean length for the ITPF was 54.0 ± 4.9 mm with a width of 22.1 ± 3.7 mm. The mean reach was 112 ± 21% (range, 90-150%) of the PCF. The ACF was less accessible with a mean reach of 67 ± 9.9% (range, 52-84%). The skull base proportions did not have a strong association on utility (p = 0.74 and 0.29). Conclusion: ITPF presents one option for ESBR of larger skull base defects. It has several limitations with access to the anterior ACF. The ITPF may be an excellent salvage flap when previous septectomy has been performed or with septal involvement by tumor. Careful preoperative assessment of potential defect can estimate the reach of the ITPF. [ABSTRACT FROM AUTHOR]

Background: Larger and more extensive lesions of the maxilla and infratemporal fossa are being successfully managed by entirely endoscopic approaches. There are still limitations in access, especially the anterolateral maxilla. The suitability of various surgical approaches was assessed in relation to surgical access achieved. Methods: Surgical access was compared in 10 cadaver heads. Five zones were defined: zone 1, nasal cavity; zone 2, medial to infraorbital nerve (ION); zone 3, lateral to ION; zone 4, anterior maxilla; and zone 5, premaxillary tissue. Endoscopic maxillary surgery consisted of standard antrostomy, modified medial maxillectomy, or complete medial maxillectomy with lacrimal duct resection. Transseptal and ipsilateral approaches were compared in each surgical state. The degree of angulations and resection zone accessed were recorded from image-guided surgery. The limits of both straight and curved instrumentation were also compared. Results: Transseptal access improved surgical access by 14.7 ± 2.5° when compared with ipsilateral approaches (p < 0.001) across all situations. The access to zone 3 across all specimens was significantly improved by 63.3-97.6% (χ2 = 20.83; p < 0.001) after all three surgical states. After complete medial maxillectomy, access to zone 4 increased from 25.0 to 85.0% (χ2 = 14.54; p < 0.001) with a transseptal approach. Conclusion: Extended endoscopic maxillary surgery combined with a transseptal option enables additional access to previously considered challenging locations. Preoperative assessment of skull base tumor, papilloma and angiofibroma extent, and resection margin will dictate surgical approach. [ABSTRACT FROM AUTHOR]

Background: Endoscopic repair of skull base (SB) defects is successful in over 90% of cases. Certain factors may contribute to failure of SB repair techniques or need for secondary repair. Methods: Five-year retrospective review of endoscopic SB defect repairs performed by a single surgeon. Results: Eighty-nine patients undergoing 110 procedures to repair 97 SB defects were evaluated. Etiology of defects included surgical/iatrogenic (64%), spontaneous (17%), traumatic (12%), congenital (6%), and idiopathic (1%). Defects occurred in the sella (41%), sphenoid sinus (18%), ethmoid roof (17%), olfactory cleft (16%), frontal sinus/recess (6%), and middle cranial fossa (2%). Sixty-three patients (71%) underwent primary SB defect repair and 26 patients underwent secondary repair (29%). In revision cases, mean number of prior repair attempts was 1.5 (range, 1-4). Factors potentially contributing to need for secondary SB defect repair included inability to localize SB defect (p =0 .008), development of new SB defect, prior sinus or SB surgery (p < 0.001), prior craniotomy (p < 0.001), prior radiation therapy (p = 0.002), and intracranial infection (p = 0.023). SB defects were successfully closed in 83 patients overall (93%), with success achieved in 97% of primary patients and 85% of secondary patients. Of failures, 3 patients required craniotomy for defect closure, 2 patients underwent permanent cerebrospinal fluid (CSF) diversion, and 1 patient has persistent CSF rhinorrhea. Conclusion: Although endoscopic repair of SB defect remains largely successful, certain factors should alert the surgeon to the potential for failure of repair or need for secondary SB defect repair. [ABSTRACT FROM AUTHOR]