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Objectives/Hypothesis: A subset of patients will undergo revision endoscopic sinus surgery (ESS) with a different otolaryngologist than the one who performed their primary surgery. The purpose of this study is to report the incidence of and clinicodemographic factors associated with a change in surgeon for revision ESS. Study Design: Retrospective cohort study. Methods: Adult patients who underwent at least two outpatient ESS procedures between 2009 and 2014 using the State Ambulatory Surgery Database for Florida were included in the study. Change in surgeon was defined by a change in a unique provider identifier for the revision procedure. Multivariable regression analysis was used to determine characteristics associated with a change in surgeon. Results: A total of 2,963 patients were included. For the revision procedure, 47.7% of patients changed their surgeon. On multivariable logistic regression, a medium‐ (odds ratio [OR]: 0.64; 95% confidence interval [CI]: 0.53‐0.77) or high‐volume (OR: 0.50; 95% CI: 0.42‐0.61) surgeon performing the index surgery and advanced age (≥65 years) (OR: 0.79; 95% CI: 0.63‐0.99) were associated with decreased odds of surgeon change for revision ESS. Longer time elapsed between index and revision surgery (OR: 1.15; 95% CI: 1.13‐1.17) was associated with increased odds of surgeon change. Conclusions: Nearly half of patients who undergo revision ESS select a surgeon other than the one who performed their primary procedure. Surgeon volume, age, and time between surgeries affect the likelihood of a change in surgeon for revision ESS. These findings may provide introductory insights into patient preferences and decision making in the surgical management of recalcitrant chronic rhinosinusitis. Level of Evidence: 4 Laryngoscope, 131:E1049–E1053, 2021 [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: Socioeconomic and demographic factors have a significant impact on healthcare utilization and surgical outcomes. The effect of these variables on baseline symptom severity and quality of life (QOL) after endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) is not well established. Our goal was to investigate the association of sociodemographic factors on QOL before and after ESS, as reflected by the 22-item Sino-Nasal Outcome Test (SNOT-22) score.Study Design: Retrospective case series.Methods: From October 2016 to August 2018, 244 patients with chronic rhinosinusitis who underwent ESS were included. Socioeconomic and demographic data, surgical characteristics, and baseline and postoperative SNOT-22 scores were recorded. Univariate and multivariate regression were performed to identify determinants of baseline symptom severity and improvement following ESS.Results: Nonwhite patients reported worse baseline symptoms severity (SNOT-22, 52.06 vs. 43.76, P = .021) compared to white patients, yet lower CRS symptoms at follow-up (SNOT-22, 23.38 vs. 28.63, P = .035). Relative improvement was higher in nonwhite patients as well (41.2% vs. 36.5%, Mann-Whitney U = 1,747, P = .015). In an adjusted multivariate logistic regression model, below-median income ($71,805 [California]) was associated with worse baseline symptom severity (β = 7.72; 95% confidence interval [CI]: 1.10, 14.26). Nonmarried patients (β = 6.78; 95% CI: 2.22, 13.48) and white patients (β = 8.45; 95% CI: 0.40, 13.97) had worse QOL at follow-up.Conclusions: Nonwhite patients and those with below-median income present with more severe CRS symptoms at baseline. However, a greater degree of absolute and relative QOL improvement was found in nonwhite and married patients following ESS. Improved understanding of the significance of socioeconomic and demographic factors and attention to cultural differences/marital status could have a substantial impact on ESS outcomes.Level Of Evidence: 4 Laryngoscope, 130:297-302, 2020. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: Minimum clinically important differences (MCIDs) for the 22-item SinoNasal Outcomes Test (SNOT-22) in patients with chronic rhinosinusitis (CRS) electing endoscopic sinus surgery (ESS) are well described. However, similar estimations for the MCID have not been investigated for patients electing continued appropriate medical therapy (CAMT). We sought to determine MCID values for a medically treated CRS cohort and compare them to historical MCIDs associated with ESS.Study Design: Prospective observational cohort study.Methods: One hundred twenty patients with refractory CRS electing CAMT were prospectively enrolled from academic referral clinics into an observational cohort study. Baseline and posttreatment SNOT-22 survey responses were collected. Four distribution-based methods for calculating MCIDs (e.g., half-standard deviation, Cohen's d, standard error of measurement, and minimum detectable change) were used to identify a range of MCID values for SNOT-22 total and domain scores.Results: The average MCID value for SNOT-22 total scores was 8.0, whereas mean MCID values for rhinologic, extranasal rhinologic, ear/facial, psychological, and sleep symptom domain scores were 3.9, 2.5, 3.3, 3.4, and 2.9, respectively, comparable to previously reported values for patients electing ESS. Although change in SNOT-22 total scores following CAMT exceeded the MCID, none of the average SNOT-22 domain score improvements surpassed their respective MCID thresholds.Conclusions: MCID values for SNOT-22 total and domain scores in patients electing CAMT are similar to previously published MCID values associated with ESS, indicating that MCID values are independent of treatment modality selection. Therefore, despite evidence of statistical significance, CAMT for CRS may not be associated with clinically discernable improvements in average SNOT-22 domain scores.Level Of Evidence: 2c Laryngoscope, 129:31-36, 2019. [ABSTRACT FROM AUTHOR]

Objectives: Appropriateness criteria to determine surgical candidacy for chronic rhinosinusitis (CRS) have recently been described. This study stratified patients who underwent endoscopic sinus surgery (ESS) according to these new appropriateness criteria and evaluated postoperative improvements among appropriateness categories.Methods: Adult patients with uncomplicated CRS electing ESS were prospectively enrolled in a multi-institutional cohort study between March 2011 and June 2015 to assess outcomes. Subsequently, appropriateness criteria that consider preoperative medical therapy, 22-item SinoNasal Outcome Test (SNOT-22) scores, and Lund-Mackay computed tomography scores were retrospectively applied.Results: A total of 92.6% (436 of 471) were categorized as "appropriate" ESS candidates, 3.8% (18 of 471) as "uncertain," and 3.6% (17 of 471) as "inappropriate." Among uncertain patients, two-thirds (12 of 18) had identifiable reasons for undergoing ESS, most commonly oral corticosteroid intolerance (n = 6). Postoperative follow-up was available for 79% (n = 372). Clinically significant SNOT-22 improvements occurred in both appropriate and uncertain groups (all P < 0.050) but not among the inappropriate group. The inappropriate group reported less mean improvement in SNOT-22 total score compared to appropriate (P = 0.008) and uncertain (P = 0.006) groups.Conclusion: The vast majority of patients (∼93%) who underwent ESS in a multi-institutional research program were identified as appropriate candidates for surgical intervention, as defined by current appropriateness criteria. Valid considerations frequently exist for offering ESS to patients categorized as uncertain. Appropriate and uncertain candidates report similar, clinically significant SNOT-22 improvements following surgery. Patients classified as inappropriate reported significantly less improvement following ESS. Surgical appropriateness criteria may assist in predicting outcomes of ESS.Level Of Evidence: 2b. Laryngoscope, 2448-2454, 2018. [ABSTRACT FROM AUTHOR]

Objective: Medically refractory chronic rhinosinusitis (CRS) can be managed with appropriate continued medical therapy (CMT) or surgery followed by CMT. Patients who initially elect CMT and do not experience adequate symptom resolution may "cross over" to endoscopic sinus surgery (ESS). Our objective was to identify patient covariates associated with this subset of patients who elect this change in treatment modality.Study Design: Retrospective analysis of a prospective, multi-center cohort of adult patients with CRS enrolled between March 2011 and June 2015 in academic, tertiary referral clinics.Methods: Subjects who initially elected CMT were followed up to 18 months, provided a comprehensive medical history, and completed the 22-item SinoNasal Outcome Test (SNOT-22) at baseline and during 6-month follow-up intervals. Hazard regression modeling was used to identify covariates associated with elective change in treatment modality.Results: One hundred seventy-nine subjects were followed for an average 15.1 (standard deviation ± 4.6) months. Subjects who elected ESS (55 of 179) had significantly worse average endoscopy scores and reported worse SNOT-22 sleep dysfunction scores at baseline (P ≤ 0.026). For each single increasing (worsening) point of Lund-Kennedy endoscopy score, the hazard ratio (HR) of crossover increased by ∼6%. Similarly, for every point of worsening in baseline SNOT-22 total score, the hazard of treatment crossover increased by ∼2%. After covariate adjustment, only baseline SNOT-22 sleep dysfunction scores were associated with an increased risk of treatment crossover (HR = 1.07; 95% confidence interval: 1.02-1.11; P = 0.003).Conclusion: Baseline total SNOT-22 and endoscopy scores are associated with treatment crossover, but reported sleep dysfunction is the only significant independent predictor of treatment crossover.Level Of Evidence: 2c. Laryngoscope, 128:304-310, 2018. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: Endoscopic sinus surgery (ESS) is performed for patients with chronic rhinosinusitis (CRS) that have failed maximal medical therapy. This study seeks to determine the prevalence of revision surgery and factors predicting the need for revision after ESS using a large statewide surgery database.Study Design: Large retrospective cohort study using the State Ambulatory Surgery Database for the state of California between 2005 and 2011.Methods: We identified over 61,000 patients with CRS who underwent ESS, determined by Current Procedural Terminology code. We identified which patients underwent a repeat surgery, and performed multivariable modeling to determine which factors (nasal polyps, age, gender, insurance, hospital setting, ethnicity) predicted the need for revision. Adjusted odds ratios (AOR) and 95% confidence intervals are presented.Results: Of 61,339 patients who underwent ESS, 4,078 (6.65%) returned for revision ESS during the time period investigated. In a multivariable logistic regression model, positive predictors of revision were a diagnosis of nasal polyps (AOR: 1.20, 95% CI: 1.11-1.29, P < .001) and female gender (AOR: 1.20, 95% CI: 1.11-1.29, P < .001); public insurance was marginally predictive of increased reoperation (AOR: 1.10, 95% CI: 1.00-1.21, P = .048). Patients of Hispanic ethnicity were less likely to have revision surgery (AOR: 0.86, 95% CI: 0.77-0.97, P = .011). Age, income, and hospital setting were not significant predictors.Conclusions: A minority of patients with CRS who undergo ESS will have a revision surgery. This likelihood is increased in female patients and those with nasal polyps, and decreased in patients of Hispanic ethnicity, even when controlling for income, insurance, and hospital setting.Level Of Evidence: 4. Laryngoscope, 128:31-36, 2018. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: Chronic rhinosinusitis with nasal polyposis (CRSwNP) is a disease process that is driven, in part, by intrinsic mucosal inflammation. Surgery plus continued medical therapy is commonly elected by medically recalcitrant, symptomatic patients. The objective was to evaluate the prevalence of nasal polyp recurrence up to 18 months after endoscopic sinus surgery (ESS) with congruent continuing medical management.Study Design: Prospective, multicenter cohort of adult patients undergoing ESS for medically recalcitrant CRSwNP performed between August 2004 and February 2015.Methods: All patients received baseline nasal endoscopy quantified using Lund-Kennedy grading. All patients included for final analysis provided at least 6 months of postoperative endoscopy examinations. Multivariate analysis was used to identify risk factors for polyp recurrence.Results: Three hundred sixty-three CRSwNP patients having undergone ESS involving polypectomy were enrolled. A total of 244 (67%) participants had graded postoperative endoscopies with average of follow-up of 14.3 ± 7.0 months. Surgery plus postoperative medical management significantly improved endoscopy total scores at 6 months (P < .001). The recurrence of nasal polyposis 6 months after ESS was 35% (68/197), compared to 38% (48/125) after 12 months, and 40% (52/129) after 18 months. Multivariate analysis identified both prior ESS (odds ratio [OR]: 2.6, 95% confidence interval [CI]: 1.5-4.6; P = .001) and worse preoperative polyposis severity (OR: 1.4, 95% CI: 1.1-1.8; P = .016) as risk factors for recurrent polyposis.Conclusions: Polyp recurrence is common after ESS with control of polyps up to 18 months found in approximately 60% to 70% of patients. Investigation into both surgical and medical management strategies is warranted to improve upon the observed prevalence of recurrence.Level Of Evidence: 2c. Laryngoscope, 127:550-555, 2017. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: The purpose of this study is to improve patient understanding of surgical outcomes while they make a preference-sensitive decision regarding electing endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS). Study Design: Prospective observational cohort study. Methods: Patients with CRS who elected ESS were prospectively enrolled into a multi-institutional, observational cohort study. Patients' were categorized into 10 preoperative Sino-Nasal Outcome Test (SNOT-22) groups based on 10-point increments beginning with a score of 10 and ending at 110. The proportion of patients achieving a SNOT-22 minimal clinically important difference (MCID) (9 points) and the percentage of relative improvement (%) for each preoperative SNOT-22 group were calculated. A subgroup analysis based on polyp status was performed. Results: A total of 327 patients were included in this study. Patients with a SNOT-22 score between 10 and 19 had the lowest chance of achieving an MCID (37.5%) and received a relative mean worsening of their quality of life (QoL) after ESS (+18.8%). Patients with a SNOT-22 score greater than 30 obtained a greater than 75% chance of achieving an MCID, and there was a relative improvement of 45% in QoL (all < -44.9%) after ESS. Outcomes from the polyp status subgroup analysis were similar to the findings from the overall cohort. Conclusion: Outcomes from this study suggest that patients with a preoperative SNOT-22 score higher than 30 points receive a greater than 75% chance of achieving an MCID and on average obtain a 45% relative improvement in their QoL after ESS. Patients with SNOT-22 score of less than 20 did not experience improved QoL from ESS. [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis: Chronic rhinosinusitis (CRS) and migraine are common entities with overlapping symptomatology, yet little research exists that investigates the intersection of the two. This study seeks to investigate whether patients with CRS--with and without a migraine history--experience comparable quality-of-life (QOL) improvement after endoscopic sinus surgery (ESS). Study Design: Retrospective analysis of a prospective cohort. Methods: An adult population (n = 229) with medically refractory CRS was prospectively evaluated following ESS using disease-specific QOL surveys: the Rhinosinusitis Disability Index (RSDI), the Chronic Sinusitis Survey (CSS), and the Sinonasal Outcome Test-22 (SNOT-22). History of comorbid migraine was identified (n = 46), and preoperative and postoperative QOL was compared to patients without migraine (n = 183). Results: Patients migraine and CRS were more likely to be female (P = 0.023); experience allergies (P = 0.024), fibromyalgia (P = 0.009), and depression (P = 0.010); and be less likely to have nasal polyposis (P = 0.003). Objective measures of disease (endoscopy and computed tomography scores) were significantly lower in patients with migraine (P = 0.027 and P = 0.002, respectively), yet these patients scored lower on baseline RSDI and SNOT-22 scores (P = 0.025 and P = 0.019, respectively). QOL in both patients with and without migraine improved significantly after ESS (P = 0.003) and by comparable magnitudes (P ≥ 0.062). Conclusion: Patients with comorbid migraine and CRS are more likely to have less severe evidence of disease and worse preoperative baseline QOL scores. This may imply that comorbid migraine disorder, in the setting of CRS, compels these patients to seek surgical management earlier in the disease process. Regardless, ESS provides comparable improvement for both patients with and without comorbid migraine. [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis To test the osteoregenerative potential and dosing of bone morphogenetic protein-2 (BMP-2)-impregnated biomimetic scaffolds in a rat model of a mandibular defect. Study Design Prospective study using an animal model. Methods Varied doses of BMP-2 (0.5, 1, 0.5, 0.5 in microspheres, 5, and 15 μg) were absorbed onto a biomimetic scaffold. Scaffolds were then implanted into marginal mandibular defects in rats. Blank scaffolds and unfilled defects were used as negative controls. Two months postoperatively, bone healing was analyzed with microcomputerized tomography (microCT). Results MicroCT analysis demonstrated that all doses of BMP-2 induced successful healing of marginal mandibular defects in a rat mandible. Increasing doses of BMP-2 on the scaffolds produced increased tissue healing, with 15 μg demonstrating significantly more healing than all other dosing ( P < .01). Conclusions BMP-2-impregnated biomimetic scaffolds successfully induce bone healing in a marginal mandibular defect in the rat. Percentage healing of defect, percentage of bone within healed tissue, and total bone volume are all a function of BMP-2 dosing. There appears to be an optimal dose of 5 μg beyond which there is no increase in bone volume. Level of Evidence NA [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis: To determine the radiographic incidence of heterotopic ossification and the clinical incidence of neck masses secondary to heterotopic ossification in a series of patients who underwent fibula free flap oromandibular reconstruction. Study Design: Retrospective review at a university medical center. Methods: Patient database of 520 consecutive fibula free flaps from 1995 to 2010 was reviewed to identify patients who had postoperative computed tomography (CT) scans of the neck to further investigate the radiologic presence of heterotopic ossification. Patient chart review was also performed to identify patients who had clinical evidence of neck masses consistent with heterotopic ossification. Results: Of the 66 patients who had postoperative CT scans available for radiologic assessment, 43 (65%) showed heterotopic ossification of the fibula periosteum. Clinically, 14 of 520 patients (2.6%) presented with firm, level I or II neck masses that proved to be secondary to heterotopic ossification. Conclusions: Development of a firm neck mass after treatment of head and neck cancer often indicates recurrent tumor. Heterotopic ossification has not been previously reported as a potential etiology of neck masses after fibula free flap oromandibular reconstruction in the head and neck surgery literature. The radiographic incidence of this phenomenon is high, and the clinical incidence of neck masses secondary to heterotopic ossification is low. Heterotopic ossification can be distinguished from recurrent tumor on the basis of physical examination, radiographic assessment, and/or fine-needle aspiration biopsy. Awareness of heterotopic ossification should be included in the differential diagnosis of patients with a neck mass who have undergone fibula free flap reconstructions. [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis: Selective reinnervation of the posterior cricoarytenoid muscle with a single phrenic nerve rootlet has been shown to restore physiologic motion in animal models. However, clinical translation of this work is challenged by the limited knowledge of the cervical anatomy of the phrenic nerve. Study Design: Prospective collaborative study. Methods: Dissection of 111 cadaveric necks (88 embalmed and 23 unembalmed) from 56 cadavers. Results: The mean (standard deviation) lengths of unembalmed cadaver C3, C4, and C5 nerve rootlets were 3.9 (2.4), 3.6 (2.6), and 0.5 (0.8) cm, respectively. Embalmed cadavers had shorter C3 and C4 phrenic nerve rootlet lengths than unembalmed cadavers ( P = .02 and P = .03, respectively). There was no difference in mean nerve rootlet length based on sex, body height or weight, or side of dissection. A total of eight unique phrenic nerve rootlet patterns were identified. The most common pattern consisted of phrenic with single C3 and C4 rootlets with an immeasurable C5 rootlet, which was present in 30 of 111 (26%) of the necks. The classic three branching pattern of single C3, C4, and C5 rootlets was found in 25 of 111 (22%) of the necks. Six of 111 (5%) of the dissections displayed accessory phrenic nerves arising from the C3, C4, or C5 anterior rami. A χ2 analysis showed no difference between side or sex and frequency of pattern. Conclusions: The present study demonstrates the wide variability within the cervical anatomy of the phrenic nerve. [ABSTRACT FROM AUTHOR]

Objectives: To illustrate a case report of a rare location for recurrence of a primary parotid pleomorphic adenoma (PA) and to demonstrate via video the transnasal endoscopic approach for resection of tumors of the anterior skull base. Study Design: Case report and review of the literature. Methods: A patient is presented with recurrent PA, originally with a right-sided deep lobe parotid and parapharyngeal space tumor that was resected 18 years ago. Her first recurrence was discovered in 2001, and since then she has had multiple recurrences in the peri-parotid tissue, the neck, and the nasopharynx for which she has undergone five separate surgeries as well as radiation. The patient presented rightsided trigeminal pain and numbness. MRI demonstrated a large enhancing mass in the sphenoid sinus with erosion of the clivus, displacing the pituitary and optic chiasm. There was widening of the foramen ovale as well as involvement of the right cavernous sinus and Meckel's cave. Results: The patient underwent a transnasal endoscopic resection of the sphenoid and anterior skull base mass in piecemeal fashion without complication. Postoperatively, no residual enhancing tumor was seen within the remaining sphenoid sinus and adjacent nasopharynx. Conclusions: Recurrent PA is a difficult disease to treat with great morbidity secondary to repeat operations and the tendency for the disease to recur. For lesions of the anterior skull base, endoscopic resection is safe and preferable, carrying less morbidity compared to open procedures. The open cavity allows easy access for regular inspection for recurrent disease. [ABSTRACT FROM AUTHOR]

Educational Objective: At the conclusion of this presentation the participants should be able to describe this newly described phenomenon associated with fibula free flap oromandibular reconstruction. Objectives: To determine the radiographic incidence of heterotopic ossification and the clinical incidence of neck masses secondary to heterotopic ossification in a series of patients who underwent fibula free flap oromandibular reconstruction. Study Design: Retrospective review at a university medical center. Methods: Patient database of 520 consecutive fibula free flaps between 1995-2010 were reviewed to identify patients who had postoperative CT scans of the neck to further investigate the radiologic presence of heterotopic ossification. Patient chart review was also performed to identify patients who had clinical evidence of neck masses consistent with heterotopic ossification. Results: Of the 66 patients who had postoperative CT scans available for radiologic assessment, 43/66 (65%) showed heterotopic ossification of the fibula periosteum. Clinically, 14/520 patients (2.6%) presented with firm, level I or II neck masses that proved to be secondary to heterotopic ossification. Conclusions: Development of a firm neck mass after treatment of head and neck cancer often indicates recurrent tumor. Heterotopic ossification has not been previously reported as a potential etiology of neck masses after fibula free flap oromandibular reconstruction in the head and neck surgery literature. The radiographic incidence of this phenomenon is high, while the clinical incidence of neck masses secondary to heterotopic ossification is low. Heterotopic ossification can be distinguished from recurrent tumor on the basis of physical examination, radiographic assessment, and/or fine needle aspiration biopsy. Awareness of heterotopic ossification should be included in the differential diagnosis of patients with a neck mass who have undergone fibula free flap reconstructions. [ABSTRACT FROM AUTHOR]