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Objective: Balloon sinuplasty (BSP) is associated with varied practice patterns. This study sought to identify otolaryngologist characteristics associated with BSP utilization. Study Design: Retrospective analysis of Medicare claims data and the National Physician Compare database. Methods: Outlier otolaryngologists were compared to non‐outliers. Otolaryngologist characteristics included sex, practice size, geographic setting, years of experience, procedure setting, 10 or fewer endoscopic sinus surgeries per year for 3 or more years, and high number of services per unique Medicare beneficiary. Outlier status was defined as performing an annual total of balloon procedures of 2 standard deviations (SDs) above the mean for all otolaryngologists in the same year. Results: Between January 2012 and December 2017, 1,408 otolaryngologists performed 101,662 endoscopic sinus surgeries and 97,680 BSP procedures. Sixty‐six outlier otolaryngologists (4.7%) accounted for 44.3% of all BSP procedures. Outlier status was associated with practice size of 10 or fewer individual providers (OR, 5.15; 95% CI, 2.73–9.74; P <.001), performance of 10 or fewer total endoscopic sinus surgeries per year for 3 or more years (OR, 3.90; 95% CI, 1.59–9.57; P =.003), and high number of overall services per beneficiary (OR 6.70; 95% CI, 1.19–37.84; P =.031). Provider sex, years of experience, and geographic setting were not associated with outlier status. Conclusion: Outlier BSP patterns are associated with a few otolaryngologists who are more likely to be identified in small practices and record low numbers of endoscopic surgeries. Although BSP is an appropriate and effective tool, identification of outlier patterns may help to facilitate peer‐to‐peer counsel. Level of Evidence: 3 Laryngoscope, 132:1340–1345, 2022 [ABSTRACT FROM AUTHOR]

The lateral recess of a well-pneumatized sphenoid sinus is challenging to access surgically. Traditional methods require the use of multiple angled endoscopes and curved instruments which may limit visualization. We describe a prelacrimal-transpterygoid/maxillary approach which offers direct access to this region with a 0° endoscope. Laryngoscope, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/Hypothesis: For patients with obstructive sleep apnea (OSA) undergoing sinonasal surgery, there is a lack of consensus on the risk and appropriate postoperative use of continuous positive airway pressure (CPAP). The aim of this study was to assess the tolerability of restarting CPAP on postoperative day one. Study Design: Prospective cohort study. Methods: A prospective study on patients with OSA on CPAP who required a septoplasty/turbinectomy and/or functional endoscopic sinus surgery (FESS) was performed. Data from the memory card of a patient's CPAP machine and subjective information were obtained on the day of surgery and at scheduled follow‐up visits. All subjects were instructed to restart CPAP on the first postoperative night. Results: A total of 14 patients were analyzed; nine underwent FESS and five had a septoplasty/turbinectomy. There were no postoperative complications encountered. The only significant change in the first postoperative week was a reduction in the percentage of nights used over 4 hours (P <.05). By the third postoperative visit, average 22‐item Sino‐Nasal Outcome Test, Nasal Obstruction Symptom Evaluation, and CPAP tolerance scores improved from preoperative values. CPAP pressures, residual apnea–hypopnea index, and number of hours and mean percentage of nights used remained stable throughout the study period. Conclusions: Both quality‐of‐life and CPAP outcomes improved or remained the same when restarting CPAP immediately postoperatively. Combined with a lack of significant complications, this study suggests that CPAP is well‐tolerated when restarted the day after a septoplasty/turbinectomy or FESS. Level of Evidence: 4 Laryngoscope, 131:E1013–E1018, 2021 [ABSTRACT FROM AUTHOR]

Objective: Studies have demonstrated improvement in Eustachian tube dysfunction (ETD) symptomatology after functional endoscopic sinus surgery (FESS); however, factors associated with ETD symptom alteration have not been elucidated. This study evaluated factors associated with improvement and normalization of ETD symptoms after FESS. Methods: A case‐control study was performed of FESS patients who had clinically significant ETD symptoms based on the Eustachian Tube Dysfunction Questionnaire‐7 (ETDQ‐7 ≥ 2.1) without middle ear effusion (MEE) preoperatively. Study patients were identified as those with a normalized ETDQ‐7 at 2 months postoperatively. Controls were patients whose ETDQ‐7 did not normalize at 2 months. Demographics, surgery characteristics, chronic rhinosinusitis phenotype, Lund‐Mackay score, temporomandibular joint dysfunction (TMJD), preoperative ETDQ‐7 and SNOT‐22 scores, and tympanograms were analyzed. Univariate and multivariate analyses were performed comparing study cases and controls. Results: Data were collected on 165 patients, with 46% patients having clinically significant preoperative ETD and 60 patients meeting final study inclusion/exclusion criteria. FESS was associated with both SNOT‐22 and ETDQ‐7 improvement (P < 0.001). Nasal polyposis was associated with a higher probability of ETDQ‐7 normalization (OR 4.429, P = 0.035). Factors associated with failure of ETDQ‐7 normalization included TMJD (OR 0.086, P < 0.001, 95% CI 0.019–0.391) and high preoperative ETDQ‐7 (OR 0.140, P = 0.006, 95% CI 0.032–0.613). Conclusion: In patients with clinically significant ETD symptoms without MEE, FESS was associated with ETDQ‐7 improvement. Nasal polyposis was associated with an increased probability of normalization of ETD symptoms postoperatively, whereas TMJD had a negative association. Level of Evidence: 3b Laryngoscope, 2019 [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: The surgical versus medical management of subperiosteal abscess can be controversial. The purpose of this study was to summarize current literature and provide pooled analyses to help direct management decisions.Study Design: Systematic review and meta-analysis.Methods: Patients <18 years old with subperiosteal abscess secondary to acute sinusitis were reviewed, and a meta-analysis was conducted. Studies including five or more patients written in English were the primary search focus.Results: Thirty-eight studies met inclusion criteria for the systematic review, and seven studies contained sufficient data for the meta-analysis. A total of 1,167 patients between the ages of 10 days and 18 years were included. Eleven sign/symptom categories were identified, with restricted ocular motility (n = 289, 45.9%), proptosis (n = 277, 44%), and fever (n = 223, 35.4%) being most frequent. Staphylococcus aureus was the most common pathogen isolated from cultures. Patients with abscess volume greater than the threshold specified in each individual study were over three times more likely to require surgical intervention compared to those with smaller abscess volume (pooled risk ratio [RR] = 3.61, 95% confidence interval [CI]: 2.40-5.44). Proptosis and gaze restriction also significantly predicted surgical intervention (pooled RR = 1.65: 95% CI: 1.29-2.12 for proptosis/pooled RR = 1.90; 95% CI: 1.20-3.00 for gaze restriction).Conclusions: Approximately half of patients with a subperiosteal abscess undergo surgical drainage. Abscess volume appears to be the most significant predictive risk factor. Detailed data from future studies regarding radiologic and ophthalmologic parameters are needed to provide more definitive values predictive of which patients are likely to fail medical therapy.Level Of Evidence: 2a Laryngoscope, 2020. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: This study analyzes the treatment outcomes of frontal inverted papillomas (FIPs) in an attempt to provide guidelines for surgery selection.Study Design: Retrospective case series.Methods: The treatment results of 29 FIPs classified into five categories were retrospectively analyzed. The five categories are F1, tumor prolapsed into frontal sinus, tumor origin outside frontal sinus; F2, tumor origin inside frontal sinus, medial to the plane of lamina papyracea; F3, tumor origin inside frontal sinus, lateral to the plane of lamina papyracea; F4, bilateral; and F5, extrasinonasal.Results: Of the 11 F1 cases, 73% had Draf I and 27% had Draf IIA procedures. There was one (9%) frontal recurrence and one (9%) frontal stenosis. Of the 10 F2 cases, 10% had Draf I, 40% had Draf IIA, 40% had Draf IIB, and 10% had Draf III surgery with a trephination. One patient (10%) had a frontal recurrence. Of the five F3 cases, 40% had Draf IIA surgery, 20% had external frontoethmoidectomy, and 40% had external frontal sinusotomy. The recurrence rate was 60%, and frontal stenosis rate was 60%. The two F4 cases had external frontal sinusotomies and Draf III surgery with no frontal recurrence or stenosis. The patient with the F5 had a frontal recurrence after Draf IIA surgery and external frontoethmoidectomy.Conclusions: Draf I or IIA surgery is adequate for most F1 tumors, and Draf II surgery is adequate for most F2 tumors. F3 and F4 tumors can be managed initially by Draf III surgery with external frontal sinusotomy added when required. F5 tumors probably require combined surgical approaches.Level Of Evidence: 4 Laryngoscope, 130:1622-1628, 2020. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: To quantify and analyze the concurrent performance of rhinoplasty (RP) (with or without septoplasty) and functional endoscopic sinus surgery (FESS).Study Design: Cross-sectional analysis.Methods: Current Procedural Terminology codes were used to extract cases of RP (n = 22,360), FESS (n = 99,173), and concurrent RP with FESS (RP + FESS) (n = 1,321) within the State Ambulatory Surgery Databases of California, Florida, Maryland, and New York from 2009 to 2011. Patient demographics, surgeon volume, charge, concurrent nasal procedures, and operating room (OR) time were compared.Results: Among the 1,321 RP + FESS combination cases, a majority involved primary rhinoplasty (n = 697, 52.8%), followed by nasal valve repair (n = 563, 42.6%) and revision rhinoplasty (n = 61, 4.6%). High-volume (n > 30), medium-volume (n = 10-30), and low-volume rhinoplasty surgeons (n ≤ 9) were observed to perform a similar number of FESS + RP combination surgeries (153, 152, and 155, respectively). A majority of RP + FESS involved two or fewer sinuses (65%). Mean OR time for RP + FESS was 189.4 ± 4.2 minutes, approximately 50 minutes shorter than the sum of standalone RP performed individually (138.8 ± 1.0 minutes) and standalone FESS (102.9 ± 0.4 minutes).Conclusions: RP + FESS more frequently involved fewer sinuses (compared with FESS alone) and was also less likely to involve revision rhinoplasty (compared with rhinoplasty alone); therefore, these cases may be selected for lower sinus disease burden and less complex rhinoplasty compared to standalone procedures. Procedures combining rhinoplasty and sinus surgery had a reduction in OR time compared to the hypothetical sum of two standalone procedures.Level Of Evidence: NA Laryngoscope, 130:E311-E319, 2020. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: Balloon sinuplasty has become an increasingly popular option for patients undergoing surgical treatment of sinusitis. This study analyzes utilization and growth of these procedures across a large cohort of patients over a 5-year period.Study Design: Retrospective data review.Methods: This was a retrospective review of Medicare utilization and billing data. Utilization and payment values were obtained from Medicare claims data using Centers for Medicare and Medicaid Services datasets. All Medicare claims were analyzed from 2012 to 2016. Data were extracted for balloon sinuplasty and endoscopic sinus surgery claims. Procedure location, total submitted claims, charges, and payments were compared.Results: From 2012 to 2016, the number of balloon procedures increased from 5,603 to 25,640. Traditional endoscopic sinus surgery procedures increased from 15,509 to 18,164. Aggregate Medicare payments to otolaryngologists for endoscopic sinus surgery have remained relatively stable, whereas there has been a 450% increase in total payments to providers of balloon sinuplasty. In 2016, total payments to providers of balloon procedures ($40.5 million) were substantially higher than payments to providers of non-balloon-based endoscopic sinus surgery ($4.7 million). The number of providers performing balloon procedures has increased 277% versus 17% for traditional sinus surgery.Conclusions: There has been a rapid expansion in the number of sinus procedures in the Medicare population from 2012 to 2016. Office-based balloon procedures account for the overwhelming majority of the increases in procedures and payments. Per procedure and aggregate payments are now higher for sinuplasty procedures than for traditional sinus surgery.Level Of Evidence: NA Laryngoscope, 129:2224-2229, 2019. [ABSTRACT FROM AUTHOR]

Objectives: Poor wound healing as reflected by the development of synechia and osteitis after endoscopic sinus surgery may trigger disease recurrence. Animal models provide insights into the pathogenesis of poor wound healing and may aid in the development of new therapeutics. Here, we established a mouse model of nasal wound healing and confirmed its utility.Study Design: Animal study.Methods: Unilateral intranasal wounds were induced using a small interdental brush in 6-week-old C57BL/6 mice. Forty-five mice were divided into three groups (each n = 15): one control and two experimental groups (intranasal vs. intraperitoneal dexamethasone). Mice were sacrificed on days 2, 14, and 28 after injury (each n = 5). Serial changes in nasal wound histopathology were described, and intergroup differences were analyzed.Results: On day 2, mucosal detachment, hemorrhage, and exudate were observed. On day 14, synechiae featuring neo-osteogenesis (bone lacunae, osteoblasts, and multinucleated osteoclasts) between the septum and the maxilloturbinate were prominent, followed by wound maturation on day 28: fewer lacunae and smaller osteoblasts. Macrophages were evident only on day 2, and lymphocytes were predominant on day 28. The amount of exudate on day 2 and the synechial area on day 28 were significantly reduced in mice that received dexamethasone systemically compared with control mice, with similar trends in those treated intranasally.Conclusion: Our mouse model of nasal wound healing was characterized by the development of bony synechia and neo-osteogenesis, not soft-tissue synechia. The model may be useful in the assessment of novel therapeutics to prevent those wounds.Level Of Evidence: NA Laryngoscope, 129:E266-E271, 2019. [ABSTRACT FROM AUTHOR]

Objective: Investigation of the postoperative olfactory function after sinus surgery for chronic rhinosinusitis (CRS) with and without polyps in a review.Data Sources: PubMed.Review Methods: A comprehensive literature search was conducted through June 2018 using relevant keywords. The titles/abstracts were reviewed to identify studies evaluating the sense of smell in CRS-patients pre- and postoperatively by either using the whole or parts of the University of Pennsylvania Smell Identification Test or the Sniffin' Sticks test. Study characteristics and outcome data of the included studies were extracted.Results: In total, 106 studies were retrieved. Twenty-four studies comprising 1,956 patients were included after quality assessment. The number of patients investigated per study was 19 to 206. In the 24 studies, 959 patients with nasal polyps and 516 without nasal polyps were described. The follow-up times varied between 0.5 and 28 months. Twenty-three studies reported an improved sense of smell, at least in certain subgroups. An overall improvement was seen in approximately 50% of the included patients. Nasal polyposis and preoperative anosmia were associated with a higher chance of improvement in olfaction. In those studies that commented on deterioration after sinus surgery, a decrease in olfaction was found in a range from 0% to 10% of cases.Conclusion: Olfaction can be improved by sinus surgery in about every second patient, especially if the patient had chronic rhinosinusitis with polyps, was anosmic, and had no prior surgery. A deterioration of sense of smell after surgery is rare. Laryngoscope, 129:1053-1059, 2019. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: Opioid-related deaths in the United States have increased 200% since 2000, in part due to prescription diversion from patients who had a surgical procedure. The purpose of this study was to characterize provider prescription patterns and assess patient-reported opioid use after endoscopic sinus surgery (ESS).Study Design: Retrospective chart review.Methods: Patients who underwent ESS between May 2017 and May 2018 were included. Opioid prescription, operative details, and postoperative opioid use data were extracted. The Massachusetts Prescription Awareness Tool (MassPAT) was queried to determine if patients filled their prescription.Results: One hundred fifty-five patients were included. Nearly all patients received an opioid prescription (94.8%). An average of 15.6 tablets was prescribed per patient. Among 116 patients with MassPAT data, 91.4% filled their prescription. Among 67 patients who reported the number of tablets they had used at the time of first follow-up appointment, 73.1% reported taking no opioids. Mean number of tablets prescribed was significantly greater among patients who underwent primary versus revision surgery (16.5 vs. 13.5, P = .0111) and those who had splints placed (21.5 vs. 15.1, P = .0037). Predictors of opioid use included concurrent turbinate reduction (58.3% vs. 14.3%, P < .0001) and concurrent septoplasty (45.5% vs. 21.6%, P = .039).Conclusions: Nearly all patients who underwent ESS were prescribed an opioid, and nearly all patients filled their prescription. However, the vast majority of patients did not require any opioid medication for postoperative pain control. As the opioid epidemic continues to persist, these findings have immediate relevance to current prescribing patterns and pain management practices.Level Of Evidence: 4 Laryngoscope, 129:1046-1052, 2019. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: Failure after sinus surgery is multifactorial, but often due to recurrence of inflammatory mucosal disease. Postoperative steroid requirements for controlling mucosal inflammation may provide insight into predicting which patients require more aggressive medical therapy to prevent disease relapse.Study Design: Retrospective chart review.Methods: A review was performed of patients who underwent functional endoscopic sinus surgery (FESS) for refractory chronic rhinosinusitis (CRS). Sino-Nasal Outcome Test-22 scores and cumulative prednisone dose (milligrams) requirements at 1, 3, and 6 months postoperatively were reviewed. A structured histopathology report of 11 variables was accessed to correlate histopathology with postoperative steroid requirements.Results: One hundred one patients were reviewed including 42 CRS with nasal polyps and 59 CRS without nasal polyps patients. CRS patients with eosinophilia required greater cumulative steroids to control disease at 1-, 3-, and 6-month postoperative intervals (P < .026, P < .007, P < .013, respectively) compared to patients without eosinophilia. Patients with tissue eosinophil aggregates required the highest cumulative steroids at 1-, 3-, and 6-month postoperative intervals (P < .003, P < .001, P < .001, respectively). When removing patients with eosinophil aggregates from the eosinophilia group, no difference persisted between patients with eosinophilia and those without eosinophilia at all intervals (P = .664, P = .735, P = .800, respectively). No other histopathology variable correlated with postoperative steroid requirement.Conclusions: Tissue eosinophil aggregates appear to be the largest driving factor for increased prednisone requirements after sinus surgery to control mucosal disease than mere presence of eosinophils. This key finding may identify patients at high risk for failure after sinus surgery and guide more proactive postoperative management.Level Of Evidence: 4 Laryngoscope, 129:794-799, 2019. [ABSTRACT FROM AUTHOR]

Objective: Antibiotics have been a mainstay of chronic rhinosinusitis therapy; however, data suggest that antibiotics may also result in several adverse unintended consequences. We aimed to evaluate if greater antibiotic use prior to sinus surgery was associated with differences in surgical outcomes.Methods: Adult CRS patients enrolled in a prospective, multi-institutional, observational cohort study were asked to recall systemic antibiotic use in the 90 days prior to endoscopic sinus surgery (ESS). Antibiotic use was examined in relation to demographics, disease characteristics, and outcomes.Results: Data were collected for 271 study participants followed for a mean of 14.9 [± 5.1] months across four institutions, with a mean preoperative antibiotic use of 27.8 [± 22.7] days out of the 90 preceding ESS. After ESS, significant improvement (P < 0.001) was reported for patient-reported outcome measures and endoscopy scores for the overall cohort. No bivariate correlation between preoperative antibiotic use and degree of benefit in objective clinical measures (endoscopy, Brief Smell Identification Test) was seen. Increased preoperative antibiotic use was associated with less improvement in 22-item SinoNasal Outcome Test (SNOT-22) and its rhinologic subdomain after ESS. Prevalence of achieving a minimal clinically important difference in overall SNOT-22 symptom scores was lower in those using more preoperative antibiotics, although statistical significance was not reached when adjusting for independent covariates in multivariate modeling.Conclusion: Higher amounts of previous antibiotic use do not appear to be associated with better ESS outcomes. Specific recommendations for antibiotic use as part of CRS-appropriate medical therapy prior to ESS require further study, particularly given concerns for antibiotic overuse and implications for improving outcomes in the modern healthcare era.Level Of Evidence: 2C Laryngoscope, 129:558-566, 2019. [ABSTRACT FROM AUTHOR]

Keywords: Sinus CT checklist; sinus computed tomography; sinus surgery; chronic rhinosinusitis; endoscopic sinus surgery; functional endoscopic sinus surgery; preoperative checklist; preop checklist; quality improvement; imaging EN Sinus CT checklist sinus computed tomography sinus surgery chronic rhinosinusitis endoscopic sinus surgery functional endoscopic sinus surgery preoperative checklist preop checklist quality improvement imaging E706 E708 3 11/19/20 20201201 NES 201201 INTRODUCTION Initially adopted from the airline industry, the implementation of safety checklists in the medical field saves lives by preventing easily avoidable mistakes.1 The World Health Organization surgical time out has been implemented worldwide to prevent such mistakes from occurring within the operating room and has been tremendously successful, leading to a substantial decrease in surgical mortality from 1.5% to 0.8%.2 This checklist has been adapted for use in endoscopic sinus surgery (ESS) to increase adherence to safety protocols.3 The principal function of checklists is to minimize the risk of preventable complications, but they also provide invaluable educational benefit. All patients who underwent endoscopic endonasal sinus surgery, endoscopic endonasal orbital surgery, or endoscopic endonasal skull base surgery were included. Sinus CT checklist, sinus computed tomography, sinus surgery, chronic rhinosinusitis, endoscopic sinus surgery, functional endoscopic sinus surgery, preoperative checklist, preop checklist, quality improvement, imaging. [Extracted from the article]

Objectives/hypothesis: Ethmoidectomy may be sufficient to address frontal sinus disease, but some surgeons may perform frontal recess dissection initially. Our objectives were to describe patient-associated factors with frequency of frontal sinus surgery and analyze the association with provider volume.Study Design: Retrospective cohort analysis.Methods: The 2013 State Ambulatory Surgery Databases of New Jersey, Florida, and Kentucky were queried to identify adults who underwent anterior ethmoidectomy or total ethmoidectomy using standard Current Procedural Terminology codes. Univariate and multivariate logistic regression was performed to determine the odds of undergoing concurrent frontal sinus exploration along with ethmoidectomy, adjusting for age, gender, race, insurance type, median income, and the metropolitan designation by zip code. We also examined provider and center volume, use of image guidance, and total charges.Results: There were 10,564 ethmoidectomies, of which 4,726 had concurrent frontal sinus surgery. Women were less likely to have frontal sinus surgery (P = .0011), as were patients with Medicare (P = .007). Hispanics were more likely to have frontal sinus surgery (P = .0003). Surgeons with higher surgical volumes were more likely to perform frontal sinus surgery; it was also more likely to be performed in centers where more sinus procedures occurred (P < .0001, both).Conclusions: Variation in the utilization of frontal sinus surgery is associated with patient sex, ethnicity, insurance status, geography, as well as provider and hospital volumes. These data support the idea that nonclinical factors may influence the treatment of frontal sinus disease.Level Of Evidence: 4. Laryngoscope, 128:2008-2014, 2018. [ABSTRACT FROM AUTHOR]

Objective: To describe sinus procedure trends from 2000 to 2014, particularly following the introduction of balloon sinuplasty Common Procedural Technology (CPT) codes in 2011.Study Design: Retrospective review of Medicare billing data available to the public.Methods: Procedure and beneficiary data from 2000 to 2014 and provider data from 2012 to 2014 were obtained online from the Centers for Medicare and Medicaid Services. Sinus CPT codes were classified as balloon sinus procedure (BSP) or nonballoon sinus procedure (nBSP). Providers billing for sinus procedures were categorized as BSP only, nBSP only, or both. For comparison, data on septoplasty procedures from 2000 to 2014 were obtained.Results: From 2000 to 2014, the total number of sinus procedures per 10 thousand beneficiaries (PP10K) nationwide increased by 3.7% annually. From 2011 to 2014, nBSP PP10K decreased by 3.1% annually, and BSP PP10K increased by 59% annually. Septoplasty PP10K changed by < 1% annually between 2000 and 2014. States with the highest BSP PP10K from 2012 to 2014 were Kansas, Texas, and Louisiana. Providers performing sinus procedures increased by 30.9% from 2012 to 2014. There was a 244% increase in BSP-only providers, a 0.7% increase in nBSP-only providers, and an 83.3% increase in providers using both. Septoplasty providers increased by 4.1%.Conclusion: Although the total number of sinus procedures increased from 2000 to 2014, the number of BSP increased at a substantially greater rate since the introduction of CPT codes for these procedures in 2011. Nationwide increases in sinus providers were driven by new providers performing balloon-guided procedures.Level Of Evidence: 4. Laryngoscope, 127:1976-1982, 2017. [ABSTRACT FROM AUTHOR]

Bioabsorbable corticosteroid-eluting sinus stents (BCES) are used to optimize healing after sinus surgery. We report a patient with BCES placed through a dural defect. A 70 year old underwent sinus surgery. Postoperatively, the patient developed mental status changes. The patient was taken to the operating room and eight BCES were identified, with one extending through the skull base. The stents were extracted and the defect was repaired. The patient recovered well. This is the first significant complication associated with BCES. Thorough review of preoperative imaging, understanding of skull base anatomy, and careful use of BCES are critical for safety. LEVEL OF EVIDENCE: NA Laryngoscope, 129:1494-1496, 2019. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: The primary objective of this pilot study was to define the change in productivity costs following endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS). Secondary objectives were to identify CRS-related characteristics that may influence the degree of productivity improvement after ESS.Study Design: Prospective, multi-institutional, observational cohort study.Methods: The human capital approach was used to define productivity costs. Annual absenteeism, presenteeism, and lost leisure time were quantified to define annual lost productive time (LPT). LPT was monetized using the annual daily wage rates obtained from the 2012 US Census and the 2013 US Department of Labor statistics.Results: Twenty-seven patients with refractory CRS who underwent ESS were followed for a mean of 15 months (range, 8-25 months). Following ESS, there were improvements in annual absenteeism (22 days reduced to 3 days), annual presenteeism (41 days reduced to 19 days), and annual household days lost (12 days reduced to 6 days). Overall, the preoperative productivity costs were reduced after ESS ($9,190 vs. $3,373, respectively; P < .001).Conclusions: Daily productivity is negatively impacted by the presence of CRS. The outcomes from this study provide the first insights into the reduced productivity costs associated with receiving ESS for refractory CRS. Future studies with larger sample sizes will need to validate the results from this pilot study.Level Of Evidence: 2c Laryngoscope, 126:570-574, 2016. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: Topical sinus irrigations play a critical role in the management of sinonasal disease, and the improvement in irrigant penetration into the sinuses postoperatively greatly contributes to the success of endoscopic sinus surgery. Prior investigations on postoperative sinus irrigations have been mostly limited to cadaver studies, which are labor intensive and do not capture the full dynamics of the flows. A pilot study was conducted to investigate the impact of surgery on sinus irrigation through computational fluid dynamics (CFD) simulations.Study Design: Retrospective computational study.Methods: Pre- and postoperative computed tomography (CT) scans were obtained on a patient who underwent standard endoscopic surgeries for all sinuses, including a Draf III frontal sinusotomy. CT-based pre- and postoperative CFD models then simulated irrigations of 120 mL saline per nostril at 12 mL/s (typical of Sinugator) and 60 mL/s (SinusRinse Bottle), in two head positions: face parallel and at a 45° angle to the ground.Results: Overall, surgery most significantly improved frontal sinus irrigation, but surprisingly resulted in less maxillary and ethmoid sinuses penetration. This may due to the partial removal of the septum during the Draf III, causing most fluid to exit prematurely across the resected septum. Higher flow rate slightly improved ethmoid sinus irrigation, but resulted in less preoperative contralateral maxillary sinus penetration.Conclusions: CFD modeling of sinonasal irrigations is a novel technique for evaluating irrigant penetration of individual sinus cavities. It may prove useful in determining the optimal degree of surgery or the ideal irrigation strategy to allow for maximal and targeted sinus irrigant penetration.Level Of Evidence: NA Laryngoscope, 126:E90-E96, 2016. [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis To assess relevant variations in the anatomical course of the infraorbital nerve (ION). This understanding may reduce the risk of surgical injury. Methods A total of 100 consecutive computed-tomography sinus studies obtained in a tertiary referral center were reviewed, and measurements were made of the 200 IONs. Anatomic variants were classified into three types based on the degree to which (if any) the nerve's course descended from the maxillary roof into the sinus lumen. Results A total of 60.5% of IONs were entirely contained within the sinus roof. In 27.0%, the nerve canal descended below the roof but remained juxtaposed to it. In 12.5%, the ION descended into the sinus lumen. The proportion of IONs descending into the sinus significantly increased to 27.7% when an infraorbital ethmoid cell was present (chi-square P < 0.001) and to 50% when the nerve was contained within a lamella of such a cell (chi-square P < 0.001). Descended nerves terminated in a foramen located an average of 11.9 ± 2.5 mm below the infraorbital rim, significantly further below the orbit than nondescended nerves ( t test P < 0.001). Descended nerves were located a mean distance of 8.6 ± 2.9 mm below the sinus roof and traversed the sinus lumen diagonally for a mean length of 15.4 ± 3.1 mm. Conclusions Descent of the ION into the maxillary sinus is a common anatomic variant that is more prevalent in the setting of an ipsilateral infraorbital ethmoid cell. Descended nerves are associated with the foramen significantly further below the inferior orbital rim than those of nondescended nerves. These observations may help surgeons avoid iatrogenic ION injury. Level of Evidence N/A. Laryngoscope, 125:1296-1300, 2015 [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis The efficacy of macrolides in chronic rhinosinusitis (CRS) is still under controversy. To date, only two double-blind, placebo-controlled studies have been published with differing results. None of these studies investigated the possible benefit of macrolides in the postoperative period. We conducted an investigator-initiated clinical trial using 250-mg erythromycin once a day over a period of 3 months, beginning the administration of either erythromycin or placebo 2 weeks after a surgical intervention for CRS. Study Design Randomized double-blind, placebo-controlled trial. Methods The concentrations of eosinophilic cationic protein (ECP) and myeloperoxidase in nasal secretion were chosen as primary outcome measures. Additionally, as a secondary outcome measure, changes in the Sino-Nasal Outcome Test-20 score, olfaction, saccharin transit time, nasal endoscopy score, and self-rating of nasal health using a visual analogue scale were evaluated. Results Sixty-seven patients after surgery for CRS with or without nasal polyps were screened, and 58 patients were randomized to the study groups. For the primary outcomes, the concentrations of ECP changed from 176.4 µl/l ± 79.0 to 226.1 µl/l ± 200.6 in the erythromycin group and from 186.9 µl/l ± 36.0 to 192.9 µl/l ± 189.2 in the placebo group; no statistical differences were found. Of the secondary outcomes, only the nasal endoscopy score showed a statistically significant improvement in the erythromycin group (from 2.6 ± 1.4 to 1.9 ± 1.5 points) compared to the placebo group (from 2.5 ± 1.3 to 2.6 ± 1.5 points). The subgroup of patients without nasal polyps in the erythromycin group showed a tendency to improvement in some secondary outcome criteria. Conclusions A general recommendation for long-term, low-dose erythromycin treatment after surgery for CRS cannot be given. In patients with CRS without nasal polyps, a tendency to improved parameters was detected. Level of Evidence Ib. Laryngoscope, 125:1048-1055, 2015 [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis To demonstrate construct validity of the ovine model as a tool for training in endoscopic sinus surgery (ESS). Study Design Prospective, cross-sectional evaluation study. Methods Over 18 consecutive months, trainees and experts were evaluated in their ability to perform a range of tasks (based on previous face validation and descriptive studies conducted by the same group) relating to ESS on the sheep-head model. Anonymized randomized video recordings of the above were assessed by two independent and blinded assessors. A validated assessment tool utilizing a five-point Likert scale was employed. Construct validity was calculated by comparing scores across training levels and experts using mean and interquartile range of global and task-specific scores. Subgroup analysis of the intermediate group ascertained previous experience. Nonparametric descriptive statistics were used, and analysis was carried out using SPSS version 21 (IBM, Armonk, NY). Results Reliability of the assessment tool was confirmed. The model discriminated well between different levels of expertise in global and task-specific scores. A positive correlation was noted between year in training and both global and task-specific scores ( P < .001). Experience of the intermediate group was variable, and the number of ESS procedures performed under supervision had the highest impact on performance. Conclusions This study describes an alternative model for ESS training and assessment. It is also the first to demonstrate construct validity of the sheep-head model for ESS training. Level of Evidence NA Laryngoscope, 125:539-543, 2015 [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis To study the utilization of balloon catheter dilation (BCD) compared to traditional endoscopic sinus surgery (ESS) Study Design Cross-sectional analysis Methods Cases identified by Current Procedural Terminology codes as BCD (2,717) or traditional ESS (31,059) were extracted from the State Ambulatory Surgery Databases 2011 for California, Florida, Maryland, and New York. Patient demographics, surgical center and surgeon volume, mean charge, and operating room (OR) time were compared. Results There were 33,776 patients who underwent sinus surgery in the included states in 2011. Of these, 4.6% of maxillary, 5.6% of sphenoid, and 13.9% of frontal procedures were performed using BCD. Adjusted analyses found increased use of BCD in patients with chronic diseases( P < .001). Patients who had limited sinus surgery were less likely to have BCD compared to patients who had all four sinuses instrumented ( P < .001). Surgeons who performed a medium (odds ratio 1.38 [1.14-1.65]) or high (odds ratio 1.71 [1.42-2.07]) volume of ESSs were more likely to use BCD compared to those who performed a low volume ( P < .001). However, among surgeons who utilized BCD, there was a minimal relationship between the percentage of surgeries performed with BCD and the surgeon's total number of cases ( R2 = 0.055). Compared to traditional ESS, the median charges for maxillary/ethmoid procedures (mini-ESS) involving BCD were approximately $4,500 ( P < .001) and maxillary/ethmoid/sphenoid/frontal procedures (pan-ESS) were approximately $2,950 ( P = .003) greater, whereas the median OR time involving BCD was 8 minutes less for mini-ESS procedures( P = .01) but not statistically different for pan-ESS procedures ( P = .58). Conclusions In the study sample, balloon technology was used in 8.0% of ESS cases in 2011. Procedures using BCD were on average more expensive compared to traditional ESS procedures, with minimal decrease in OR time. Level of Evidence 2c Laryngoscope, 125:49-56, 2015 [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis Determine rates and reasons for revisits after adult ambulatory sinonasal surgery. Study Design Cross-sectional analysis of multi-state ambulatory surgery and hospital databases. Methods Ambulatory adult sinonasal procedures were extracted from the State Ambulatory Surgery Databases for New York, Florida, Iowa, and California for 2010. Cases were linked to the State Emergency Department Databases and the State Inpatient Databases for visit encounters occurring 0 to 14 days after the procedure. The number of revisits (including readmissions) was determined as well as the reason for revisit. The overall rate of and intervention rate for postprocedural bleeding were determined. Results A total of 35,678 ambulatory sinonasal cases were extracted (mean age, 47.5 years). Overall, 5.0% of patients had a revisit after surgery (18.9% revisited the ambulatory surgery center, 67.0% the emergency department, and 14.1% to inpatient admission). The primary diagnoses at the first revisit were bleeding (23.0%), acute pain (3.7%), and fever/dehydration (3.8%). Overall, 0.8% of patients incurred a second revisit. Among all cases, 1.2% and 0.3% presented with a bleeding diagnosis at a first and second revisit, respectively. Among revisits, 1.0% and 17.9% underwent a procedure to control bleeding at the first and second revisits, respectively. Three deaths were noted for an overall 14-day mortality rate of 0.0084%. Conclusion There is a nonnegligible revisit rate after ambulatory sinonasal surgery. The most common reasons for revisit include bleeding, but also acute pain and fever/dehydration. These particular complications should be targeted for prevention to reduce postoperative revisit rates. Level of Evidence 2b. Laryngoscope, 124:1983-1987, 2014 [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis Sinus surgery is one of the most frequently performed surgical operations. The objective was to determine if rates of surgery have changed over the last 10 years. Study Design Secondary data analysis of the State Ambulatory Surgery Database of Florida. Methods We calculated population adjusted rates of ambulatory sinus surgery for all adults, 2000 to 2009. Result There was a substantial decrease in the proportion of patients who had surgery in a hospital setting and a substantial increase in patients who had surgery with image guidance. Population-adjusted rates of sinus surgery increased over the study period, from a mean of 104 cases per 100,000 population in 2000 to 129 per 100,000 in 2009 ( P <0.001). Procedure rates also increased, from a mean of 226 per 100,000 in 2000 to 316 per 100,000 in 2009 ( P <0.001). Rates of frontal sinus procedures more than doubled, and rates of cases in which all four sinuses were treated tripled during the same time period. A greater number of sinus procedures was associated with use of image guidance and high annual surgical case volume. The strongest predictor was the individual surgeon. Conclusion Rates of sinus surgery increased over the study period, with more patients undergoing surgery and more procedures per surgical case. The strong association of procedural patterns with specific surgeons in sinusitis care highlights the importance of future investigations to examine training, technological, and reimbursement factors that may influence surgeons' clinical decision making for this common condition. Level of Evidence 2b. Laryngoscope, 124:820-825, 2014 [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis The aims of this study were to evaluate the efficacy of functional endoscopic sinus surgery (FESS)-oriented multimodality treatment in chronic rhinosinusitis (CRS) patients with asthma and its impact on asthma. Study Design Prospective, nonrandomized cohort. Methods Twenty-seven CRS patients with asthma who underwent FESS with postoperative topical corticosteroid spray were evaluated preoperatively; 25 of them were evaluated 1 year and 3 years postoperatively. CRS was evaluated by visual analogue scale, clinical control of CRS, and objective measurement endoscopy Lund-Kennedy scores. Asthma was assessed by subjective asthma control test and asthma control level, also by objective antiasthma medication use and pulmonary function tests. Results VAS scores of general symptoms (8.09 ± 0.87 preoperatively) were significantly improved at 1 year (2.94 ± 2.21) and 3 years (3.77 ± 2.16) postoperation ( P = .000). No difference in these items was found between 1 year and 3 years ( P = .463). Endoscopy Lund-Kennedy scores at 1 year (4.34 ± 3.09) and 3 years (5.80 ± 3.38) postoperatively were significantly better (9.33 ± 2.03 preoperatively, P = .000), and there was no difference between 1 year and 3 years of follow-up ( P > .05). Significantly, asthma control level improved postoperatively ( P = .025). However, antiasthma drug and pulmonary function showed no significant change postoperatively ( P > .05). Conclusions FESS-oriented multimodality treatment improves CRS with asthma significantly and persistently. Asthma control level improved. Antiasthma medication use and pulmonary function remained stable. Level of Evidence 4. Laryngoscope, 124:24-28, 2014 [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis The objective of this study was to construct the clinical profile of patients with chronic rhinosinusitis (CRS) with/without polyposis undergoing revision sinus surgery and to evaluate the relationship of polyposis, asthma, acetylsalicylic acid (aspirin) (ASA) sensitivity, inhalant allergies, and previous sinus surgery on disease severity as measured by objective parameters. Study Design Cross-sectional study. Methods Two-hundred twenty-five patients were accrued at a tertiary care academic center. Categorical factors recorded included presence of polyps, asthma, inhalant allergy, and ASA sensitivity. Continuous variables assessed included mean number of previous sinus surgeries, Lund-Kennedy endoscopy score, Lund-Mackay computed tomography (CT) score, absolute eosinophil count (AEC), and total immunoglobulin E (tIgE) level. Statistical analysis was performed to analyze the impact of polyposis, asthma, inhalant allergy, and ASA sensitivity on objective parameters. The mean number of previous surgeries was also correlated with objective parameters. Results The mean age was 50.1 years with a male:female ratio of 1.1:1. The overall prevalence of polyposis, asthma, inhalant allergy, and ASA sensitivity was 56.4%, 48.4%, 38.7%, and 16.0%, respectively. The mean endoscopy and CT scores were 9.0 (±4.0) and 11.4 (±5.8), respectively. The mean AEC and tIgE were 0.4 k/μL (±0.4) and 161.4 IU/mL (±251.4). The mean number of previous endoscopic sinus surgeries was 1.8. Patients with CRS with polyposis had a statistically significant increase in presence of asthma (odds ratio [OR]: 7.5, P < .0001), inhalant allergy (OR: 3.6, P < .0001), and ASA sensitivity (OR: 78.6, P < .0001). Patients with polyposis had a statistically significant increase in endoscopy score ( P < .0001), CT score ( P < .0001), AEC ( P < .0001), and tIgE ( P = .0002). Patients with asthma had a statistically significant increase in endoscopy ( P < .0001) and CT scores ( P < .0001), AEC ( P < .0001), and tIgE ( P = .0002). Patients with inhalant allergy had a statistically significant increase in endoscopy ( P = .0069), CT scores ( P = .0017), and tIgE ( P = .0084) but not AEC ( P = .1492). Patients with ASA sensitivity had a statistically significant increase in endoscopy score ( P < .0001), CT score ( P < .0001), and AEC ( P = .003) but not tIgE level ( P = .186). The number of previous surgeries had a statistically significant correlation with endoscopy ( P = .006) and CT scores ( P = .03) but not AEC ( P = .48) or tIgE ( P = .66). Conclusions The current analysis constructed the clinical profile of the recalcitrant CRS patient undergoing revision sinus surgery. In general, this patient group has a high prevalence of polyposis, asthma, inhalant allergy, ASA sensitivity, and elevated disease burden as measured by objective measures. The polyp phenotype signifies statistically higher prevalence of associated comorbidities and greater objective disease severity. The presence of asthma, inhalant allergy, and ASA sensitivity also predicts statistically higher disease burden. The endoscopy and CT scores statistically correlate with the number of previous surgeries. Level of Evidence 4 Laryngoscope, 123:E1-E11, 2013 [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis: To evaluate a previously validated low-cost sinus surgery task trainer as a means of acquiring basic endoscopic sinus surgery skills and as an objective structured assessment of technical skills (OSATS) to determine procedural competency. Study Design: Prospective blinded study. Methods: Medical students (N = 52) with no sinus surgery experience learned to perform nasal endoscopy and five specific sinus surgery tasks using the validated task trainer. Training included regimented expert instruction, peer instruction/observation, and experienced-based learning. Pre- and post-training video recordings of nasal endoscopy and five sinus surgery skills were obtained. Two blinded expert otolaryngologists compared pre- and post-training performance using a checklist and global rating scale. Results: Medical student post-training performance was significantly better than pre-training performance for each checklist item and global rating scale as calculated by paired t test ( P < .001). Interrater reliability and internal consistency were confirmed by Kendall's coefficient of concordance and Cronbach's α calculations, respectively. Conclusions: The sinus surgery task trainer provides an effective means of teaching and evaluating nasal endoscopy and basic sinus surgery skills for novice surgeons. With repeated practice, there was significant improvement in performance. An OSATS using the sinus surgery task trainer suggests that we can effectively measure endoscopic sinus surgery ability with the potential to reliably determine competency outside the operating room. [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis: Virtual surgical training systems are of growing value. Current prototypes for endonasal sinus surgery simulation are very expensive or lack running stability. No reliable system is available to a notable number of users yet. The purpose of this work was to develop a dependable simulator running on standard PC hardware including a detailed anatomic model, realistic tools and handling, stereoscopic view, and force feedback. Study Design: Descriptive. Methods: A three-dimensional voxel model was created based on a high-resolution computed tomography study of a human skull, from which the bony structures were segmented. The mucosa and organs at risk were added manually. The model may be manipulated with virtual surgical tools controlled with a low-cost haptic device, which is also used to adjust microscopic or endoscopic views. Visualization, haptic rendering, and tissue removal are represented with subvoxel resolution. Results: The handling of the model is convincing. The haptic device provides a realistic feeling regarding the interaction between tool tip and anatomy. Three-dimensional orientation and the look and feel of virtual surgical interventions get close to reality. Conclusions: The newly developed system is a stable, fully operational simulator for sinus surgery based on standard PC hardware. Besides the limitations of a low-cost haptic device, the presented system is highly realistic regarding anatomy, visualization, manipulation, and the appearance of the tools. It is mainly intended for gaining surgical anatomy knowledge and for training navigation in a complex anatomical environment. Learning effects, including motor skills, have yet to be quantified. Laryngoscope, 2010 [ABSTRACT FROM AUTHOR]

Objectives: To evaluate a multidisciplinary early intervention protocol for invasive fungal sinusitis (IFS) in neutropenic patients and its effect on degree of tissue involvement at time of presentation and effect on morbidity and mortality. Study Design: Retrospective review. Methods: A chart review was performed for cases of acute fulminant IFS in neutropenic patients at Emory University Hospital from 1995 to 2007. Inclusion required tissue diagnosis of IFS, neutropenia, and adequate records of the following: tissue involvement at presentation, number and extent of surgical procedures performed, morbidity, and mortality. Group 1 included patients prior to 2001, and group 2 included patients after protocol initiation in 2001. The groups were compared for the number of tissue sites involved at presentation, number of surgical procedures performed, long-term morbidity, and mortality. Results: Twenty-eight cases of IFS were identified. The average number of sites involved at presentation was 2.5 in group 1 and 1.5 in group 2 ( P = .059). The average number of procedures was 2.2 in group 1 and 1.0 in group 2 ( P = .026). Long-term morbidity occurred in 43% (6/14) of group 1 patients compared with 7.1% (1/14) of group 2 patients ( P = .029). Mortality from IFS was 7.1% in group1 and 7.1% in group 2. Conclusions: IFS requires early diagnosis and treatment for optimum outcome. A protocol of early intervention for neutropenic patients is effective in early detection of IFS with fewer sites of involvement at diagnosis, fewer surgeries, and less long-term morbidity. No difference in survival was found, as this is more a factor of the underlying cause of the neutropenia. Laryngoscope, 119:180-183, 2009 [ABSTRACT FROM AUTHOR]

Submucous resection with powered instrumentation (SRPI) is an effective surgical method to achieve inferior turbinate (IT) reduction with minimal morbidity. We describe a series of two cases of capillary hemangioma (pyogenic granuloma) that developed in the posterior third of the IT as a late complication after SRPI. [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis: Image-guided surgery (IGS) is a critical tool. However, its clinical validity remains controversial. A review of indications and a consensus based on literature are presented. Methods: Literature review. Results: Traditional indications remain valid. Novel applications have emerged, and the reliability of IGS has been consistently endorsed. Although evidence is based on scattered reports and expert opinions, the use of IGS in approved instances is regarded as the state of the art. Conclusions: IGS is reliable, and a scientific validation of outcomes would entail unethical strategies. An expanding spectrum of indications is anticipated, although IGS does not replace proper training. [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis: The objective of this randomized, double-blind, placebo-controlled study was to assess the effect of perioperative systemic steroids on subjective and objective surgical outcomes for patients undergoing endoscopic sinus surgery (ESS) for chronic rhinosinusitis with polyposis (CRSwP). The secondary objective was to begin validation of the newly developed Perioperative Sinus Endoscopy (POSE) scoring system. Methods: Patients who had failed maximal medical therapy and were scheduled to undergo ESS were eligible for the study. Participants were randomized to receive either 30 mg of prednisone or placebo for 5 days preoperatively and 9 days postoperatively. Operative and baseline clinical data were collected using the Lund-McKay staging system including its Sinus Symptom Questionnaire as well as additional data regarding mucosal health, the technical difficulty of surgery, and endoscopic data using the Lund-Kennedy Endoscopic Score (LKES) and POSE scale. Data were also collected at 2 weeks, 1 month, 3 months, and 6 months postoperatively. A sample size of 24 was calculated to detect a clinically relevant difference between groups of 40%. Routine statistical comparisons were performed as were repeated measures analysis of variance with Bonferroni adjustment because of the multiple comparisons performed. To address the secondary objective, data were also collected at all postoperative time points using the POSE instrument, which was designed with the intention of enhancing face validity and responsiveness to change. Comparisons were performed between the POSE and LKES, including assessment of sensitivity to change, correlation between the two scales, and correlation with symptom scores. Results: Twenty-six patients participated in the study. Operative data demonstrated a significantly higher percentage of severely inflamed sinonasal mucosa in patients not pretreated with systemic steroids, which was associated with technically more difficult surgery in the estimation of the operating surgeon. In terms of postoperative symptoms, there was no difference between treatment groups, with both placebo and prednisone significantly improved over baseline up to 4 weeks postoperatively. Endoscopic assessment of patients postoperatively demonstrated a treatment effect ( P < .05), with clinically healthier cavities seen in patients treated with prednisone up to 6 months postoperatively as compared with baseline ( P < .001), although the strongest effect was seen at the 2-week time point. In comparing the two endoscopic scales, the POSE and LKES correlated highly ( R > 0.70; P < .001) both in terms of absolute score and change in score. There is some evidence that the POSE score may be more sensitive to change than the LKES, and the POSE scores did correlate more strongly with symptom scores than the LKES, although both endoscopic scores correlated only weakly with symptom scores. Conclusions: The data presented in this study support the practice of administering preoperative systemic steroids to patients undergoing ESS for CRSwP. Furthermore, in the practice of surgeons who provide intensive postoperative care post-ESS, including debridement and medical therapy based on the endoscopic findings, there is evidence to support administering systemic steroids in the postoperative period. The POSE scoring system compares favorably with the LKES and may confer advantages in terms of face/content validity and responsiveness to change and is worthy of further validation. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the prevalence and severity of individual Rhinosinusitis Task Force(RSTF) symptoms in patients with chronic rhinosinusitis(CRS) undergoing functional endoscopic sinus surgery (FESS).Methods: Retrospective analysis of prospectivelycollected data in 201 patients treated with FESS. The prevalence and severity of individual RSTF major and minor symptom scores graded on a visual analogue scale(VAS) were compared. Correlation between absolute improvement in individual symptom scores at 1-year postoperative was performed.Results: One-hundred fifty-eight of 201 patients met inclusion criteria giving a response rate of 78%. The average age was 49.4 (range 18-80) with a male-to-female ratio of 1.1:1. The preoperative leading mean symptom scores were postnasal drip (5.8 ± 0.3), nasal obstruction (5.7 ± 0.3), and facial congestion (5.1 ± 0.3).These symptoms were also the most prevalent with 82%,84%, and 79% of patients reporting these symptoms, respectively.Postoperative symptom improvements were significant (P ± .0001) across all RSTF domains except fever. The highest percentage improvement was seen with facial congestion (93%), nasal obstruction (92%), and postnasal drip (85%). Multivariate analysis revealed significant(P < .0001) high correlation between improvements of facial pain/pressure with facial congestion (R =0.72), facial congestion with nasal obstruction (R = 0.65),and facial pain/pressure with headache (R = 0.72).Conclusion: The top three RSTF symptoms were postnasal drip, nasal obstruction, and facial congestion in terms of prevalence and severity. Symptom scores improved after FESS. Of these symptoms, the degree of improvement of facial pain/pressure, facial congestion, nasal obstruction, and headache are highly correlated. [ABSTRACT FROM AUTHOR]

Objective To evaluate the clinical effects of implementing the use of a navigational system in sinus surgery in a community hospital setting. Study Design Retrospective record review. Methods The hospital records of 800 patients who had undergone sinus surgery performed by 7 physicians at one institution over 11 years were reviewed and tabulated. The information was recorded in 2 groups of 400 with those in group A being treated before the availability of an electromagnetic sinus navigational system and those in group B being treated after the unit had been installed. The following data were collected: date, age, gender, informed consent, physician, additional procedures, sinuses entered, use of navigational system, revision status, setup time, operative time, and complications. The results of the two groups were analyzed statistically, and comparisons were made. Results/Conclusions The patient populations in groups A and B were determined to have similar demographic profiles. Significantly more sinuses, specifically in the frontal location, were entered in group B compared with group A. Adjusted for the number of sinuses treated, the median operative times did not differ significantly between groups. Major and minor complication rates were similar in both groups and were consistent with the published literature. In a community hospital setting, once an electromagnetic guidance system became available, it was used in 92% of the cases performed by sev-eral otolaryngologists. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the access to the frontal recess using the axillary flap approach by identifying the frontal ostium during endoscopic sinus surgery. Study Design Prospective review of 64 consecutive patients (118 sides) undergoing axillary flap exposure of the frontal recess between November 1998 and July 1999. Methods Demographic data, identification of the frontal ostium, findings at surgery, use of nasal packing, the presence of postoperative symptoms, revision surgery, and the endoscopic appearance of the frontal recess were collected. The operative technique is presented. Results The frontal sinus ostium was identified in 96% of patients (104 of the 118 sides). Eight sides had Kuhn type 3 cells that required removal for clearance of the frontal ostium. Eighty-two percent of sides (97 sides) had endoscopically healed sinuses without symptoms after an average follow-up of 15.4 months. Six sides had middle meatal adhesions requiring division under local anesthetic. One patient has required revision surgery. Conclusion The axillary flap approach to the frontal recess provides excellent access to the frontal recess and allows clearance of cells in the recess with identification of the frontal ostium in the vast majority of cases. [ABSTRACT FROM AUTHOR]

Objective/Hypothesis To quantitatively evaluate the long-term impact of sinus surgery on paranasal sinus development in the pediatric patient. Study Design Longitudinal review of eight pediatric patients treated with unilateral sinus surgery for periorbital or orbital cellulitis with an average follow-up of 6.9 years. Control subjects consisted of two groups, 9 normal adult patients with no computed tomographic evidence of sinusitis and 10 adult patients with scans consistent with sinusitis and a history of sinus-related symptoms extending to childhood. Methods Application of computed tomography (CT) volumetrics, a technique allowing for precise calculation of volumes using thinly cut CT images, to the study and control groups. Results Paired Student t test analyses of side-to-side volume comparisons in the normal patients, patients with sinusitis, and patients who had surgery revealed no statistically significant differences. Comparisons between the orbital volumes of patients who did and did not have surgery revealed a statistically significant increase in orbital volume in patients who had surgery. Conclusions Only minimal changes in facial volume measurements have been found, confirming clinical impressions that sinus surgery in children is safe and without significant cosmetic sequelae. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: Intraoperative guidance systems have been developed which use infrared tracking technology to assist with anatomical localization during sinus surgery. Although the introduction of this technology is intended to increase the safety and efficacy of sinus surgery, little is known about its actual impact in the clinical setting. The objective of this report was to study the application and utilization of an image guidance system shared by multiple sinus surgeons in a specialty hospital. Study Design: Combined prospective case study and retrospective analysis of physician surveys. Methods: An optical-based image guidance system (LandmarX, Xomed, Inc., Jacksonville, FL) was used by 34 physicians to perform 754 sinonasal surgeries over a 2.5-year period at Massachusetts Eye and Ear Infirmary. In 19 cases, system registration was repeated during surgery to measure the effect of fiducial placement on system accuracy. Results: The measured accuracy of anatomical localization at the start of surgery (mean value, 1.69 +/- 0.38 mm) was comparable to the perceived accuracy of 1 to 3 mm that was reported by 79% of surgeons surveyed. Operating room time (mean period, 130.6 +/- 41.1 min) correlated with the surgical procedure performed (P < .05), but not with the disease stage or revision rate. According to a majority of surgeons, use of the image guidance equipment increased operating room time by 15 to 30 minutes during initial cases and by 5 to 15 minutes once experience with the equipment had been acquired. More than 90% of surgeons anticipated their continued use of the image guidance equipment for sinus surgery at a similar or greater level in the future. Conclusion: An optical-based image guidance system can be successfully integrated into a multisurgeon operating room environment. Use of the system provides accurate anatomical localization during sinus surgery and results in a relatively high level of physician satisfaction. [ABSTRACT FROM AUTHOR]

Objectives: A critical pathway was applied to patients undergoing osteoplastic flap (OPF) for frontal sinus obliteration to determine whether efficiency could be improved. Study Design: A retrospective review of consecutive OPF procedures (n = 51) performed between 1992 and July 1997 was conducted. Methods: The patient groups were subdivided into those who underwent OPF alone and those who had endoscopic sinus procedures performed in addition to OPF. Comparisons were made between the precritical pathway and post-critical pathway groups, specifically noting operative time, total operating room (OR) time, estimated blood loss (EBL), length of hospital stay, and costs. We used a critical pathway that was developed for endoscopic sinus procedures at our institution through a multidisciplinary team approach. Preoperative evaluation and testing, intraoperative equipment and medications, and postoperative care including follow-up clinic visits were all standardized. An unpaired, two-tailed Student t test was used to evaluate the data. Results: Statistically significant ( P < .05) reductions in operative times, total OR time, EBL, and length of hospital stay were observed in the post-critical pathway group who underwent endoscopic sinus procedures as well as OPF. Costs to the OR were reduced 29% and 15% for OPF and for OPF with endoscopic surgery, respectively. Patient costs were reduced 5% and 4% in these groups, respectively. Conclusions: With implementation of effective critical pathways, significant decreases in length of stay are seen, and cost reductions can be realized through the improved efficiency, shortened OR times, and decreases in redundancy of ordering materials. [ABSTRACT FROM AUTHOR]

We describe a functional endoscopic sinus surgery (FESS) technique that involves the simultaneous use of endoscope and suction in the nondominant hand that bears resemblance to chopstick use. The FESS chopstick technique reduces time for suction and improves operative field visualization. Laryngoscope, 2010 [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis Endoscopic sinus surgery in children continues to be a controversial issue. Major factors in determining when to operate are the duration of the disease and duration of medical treatment. Study Design Prospective study of children referred to a tertiary center. Patients and Methods Eighty-three patients underwent endoscopic sinus surgery for refractory chronic sinusitis. All patients were followed prospectively to evaluate their response to surgery for a mean follow-up period of at least 1 year. A χ2 analysis and logistic regression analysis were performed to determine statistical difference between duration of symptoms and outcome. Results The overall success rate of endoscopic sinus surgery was 80%. Children who had surgery between 6 and 12 months of symptoms despite continued medical therapy had an 84% success rate, those who had surgery between 12 and 18 months had a 74% success rate, and those with more than 18 months of treatment for symptoms had an 81% success rate ( P >.05). Conclusions Duration of the symptoms of chronic sinusitis in children of more than 6 months was not a predictor of success of endoscopic sinus surgery in these children. Although there seemed to be a trend toward having a more successful procedure in children who had surgery between 6 and 12 months of medical treatment versus those who had surgery after more than 12 months of medical treatment, this did not reach statistical significance. A prospective study with more patients may shed more light on this subject. [ABSTRACT FROM AUTHOR]

Endoscopic and radiological findings in patients with chronic sinusitis do not always correlate with symptoms. Studies suggest that postoperative endoscopic examination of the sinonasal cavity provides prognostic information regarding the potential for future episodes of sinusitis and the need for revision surgery. It is recommended that findings on nasal endoscopy be included in future outcomes studies on sinusitis. [ABSTRACT FROM AUTHOR]