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Objective: Identify the benefits and caveats of combining minimal access approaches to the infratemporal fossa (ITF), such as the endoscopic transnasal, endoscopic transorbital, endoscopic transoral, and endoscopic sublabial transmaxillary approaches to address extensive lesions not amenable to a single approach. The study provides anatomical metrics including area of exposure and degree of surgical freedom. Methods: Five human cadaveric specimens (10 sides) were dissected to expose and methodically analyze the anatomical intricacies of the ITF using the following minimal access approaches: endoscopic transnasal transpterygoid (EETA), endoscopic sublabial transmaxillary, endoscopic transorbital via infraorbital foramen, and endoscopic transoral techniques. Area of exposure at the pterygopalatine fossa and surgical freedom at the ITF were obtained for each approach. Results: The endoscopic sublabial transmaxillary sinus and the combined approach afford a significantly greater exposure than an isolated EETA. The difference in exposure (mean) between the endoscopic sublabial transmaxillary and EETA was 1.62 ± 0.85 cm2 (p < 0.001), and the difference between the combined approach and EETA was 4.25 ± 0.85 cm2 (p < 0.001). Conclusions: Combining minimal access endoscopic approaches to the ITF can provide significantly greater exposure than an isolated EETA; thus, providing enhanced access to address lesions with extensive involvement of the ITF, especially those with superolateral and inferolateral extensions. In addition, some approaches may have an adjunctive role to the resection, such as the endoscopic transoral approach offering the potential for early control of the internal maxillary artery and its branches, some of which may be supplying the tumor in the ITF; or the endoscopic transorbital approach yielding a direct line of sight to the superior ITF and middle cranial fossa. Level of Evidence: NA. [ABSTRACT FROM AUTHOR]

Objectives: This study aimed to ascertain the prevalence of left-handedness (LH) among otolaryngology--head and neck surgery (ORLHN) practitioners, investigate dexterity's impact on LH trainees, and identify common patterns in their training to improve the training experience. Methods: A web-based survey was distributed anonymously via email to members of the Saudi Otorhinolaryngology Society. The survey targeted ORLHN attending consultants, board-certified registrars, and current residents. It consisted of three sections: the first focused on the experience of attending consultants in training LH individuals, the second investigated common maneuvers employed by rhinologists, and the third explored the experiences and impacts reported by LH trainees. Results: The study included 174 participants, and found a 13.2% LH prevalence among them. Rhinologists showed disparities, with 50% advising trainees to stand on the left side of the bed and use their left hand for the scope, whereas the other half asked otherwise. Additionally, 94.4% of the participants had not encountered any courses specifically tailored for LH trainees. Among LH trainees, 57% and 41% reported difficulties in learning and performing side-specific procedures such as functional endoscopic sinus surgery and endoscopic septoplasty, respectively, often attempting to switch to their nondominant hand, and feeling disadvantaged due to their laterality. Conclusions: Left-handedness presents challenges for both LH trainees and their trainers in surgical specialties, particularly in ORLHN, in which specific positioning and instruments are crucial to gain access to the desired surgical field. Despite these challenges, there is insufficient support for LH individuals. We recommend encouraging LH trainees to openly disclose and discuss their left-handedness, provide them with mentors, establish standardized operating room setups and techniques, supply appropriate instruments, and demonstrate flexibility in accommodating their needs. Level of evidence: Level 5. [ABSTRACT FROM AUTHOR]

Background: This study aimed to evaluate the feasibility, safety, and early surgical outcomes of transoral robotic and endoscopic thyroidectomy conducted by a novice surgeon. Methods: We analyzed 27 patients who underwent transoral thyroidectomy between December 2018 and November 2021. All the surgeries were performed by a novice surgeon without prior endoscopic or robotic surgery experience; the surgeon had experienced 12 cases of transcervical thyroidectomy before adopting transoral thyroidectomy. Results: Of the 27 cases, 1 was converted to the transcervical approach due to poor bleeding control. Four cases had transient recurrent laryngeal nerve palsy, and three had transient hypoparathyroidism. Most of the patients were very satisfied with the postoperative cosmetic outcome. Conclusions: Transoral robotic and endoscopic thyroidectomies are feasible for the novice surgeon, with reasonable results in the early adoption stage if preparations are according to the suggested framework. Level of Evidence: Level 4. [ABSTRACT FROM AUTHOR]

Objective: Social functioning is an important factor in the evaluation of postoperative health‐related quality of life (HRQoL) for pituitary adenoma patients. In a prospective cohort study multidimensional HRQoL of non‐functioning (NFA) and functioning (FA) pituitary adenoma patients were evaluated following endoscopic endonasal surgery using the endoscopic endonasal sinus and skull base surgery questionnaire (EES‐Q). Methods: Prospectively, 101 patients were included. The EES‐Q was completed preoperatively and postoperatively (2 weeks, 3 months, 1 year). Sinonasal complaints were completed daily during the first week postoperatively. Preoperative and postoperative scores were compared. A generalized estimating equation (uni‐ and multivariate) analysis was performed to identify significant HRQoL changes related to selected covariates. Results: Two weeks postoperatively, physical (p <.05) and social (p <.05) HRQoL are worse and psychological (p <.05) HRQoL improved compared with preoperatively. Three months postoperatively, psychological HRQoL (p =.01) trended back to baseline and no differences in physical or social HRQoL were reported. One year postoperatively, psychological (p =.02) and social (p =.04) HRQoL improved while physical HRQoL remained stable. FA patients report a worse HRQoL preoperatively (social, p <.05) and 3 months postoperatively (social, p <.02 and psychological, p <.02). Sinonasal complaints peak in the first days postoperatively and gradually return to presurgical levels 3 months postoperatively. Conclusions: The EES‐Q provides meaningful information on multidimensional HRQoL to improve patient‐centred health care. Social functioning remains the most difficult area in which to achieve improvements. Despite the relatively modest sample size, there is some indication that the FA group continues to show a downward trend (and thus improvement) even after 3 months, when most other parameters reach stability. Level of evidence: Level II—B. [ABSTRACT FROM AUTHOR]

Objective: To reveal the factors affecting the incidence of chorda tympani nerve (CTN) transection during middle ear surgery. Study Design: Retrospective case review. Setting: Tertiary referral center. Patients We analyzed 232 ears (117 ears with cholesteatoma, 101 ears with chronic otitis media, and 14 ears with otosclerosis) that underwent tympanoplasty or stapes surgery during 2017–2020. Intervention: Eighty‐four ears underwent transcanal endoscopic ear surgery (TEES), 103 ears underwent microscopic ear surgery (MES), and 45 ears underwent surgery using both endoscopy and microscopy (Dual). Main Outcome Measure: To confirm CTN transection, intraoperative endoscopic/microscopic video images were evaluated. We used the same video images to determine the anatomical variation of the CTN course in the middle ear. Results: In 18 ears (7.8%: 6/84 TEES ears [7.1%], 6/103 MES ears [5.8%], and 6/45 Dual ears [13.3%]), the CTN was cut during middle ear surgery. There was no significant difference in CTN transection among groups. In cholesteatoma patients, stapes involvement resulted in a significantly higher CTN transection incidence. CTN anatomical variants such as the "Attached Short type" and "Ultrashort type" showed a significantly higher CTN transection incidence. Conclusion: Although endoscopic surgery did not reduce the incidence of CTN transection during middle ear surgery, pathological involvement of the stapes and CTN anatomical variants, such as the "Attached Short type" and "Ultrashort type," may increase this incidence. Preoperative evaluation of stapes involvement and anatomical location of the CTN course could help identify patients at greater risk for iatrogenic CTN transection. Level of Evidence: 4. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study is to assess the anatomical appropriateness of a three‐dimensional (3D) printed pediatric middle ear model with a replaceable middle ear unit as an endoscopic ear surgery (EES) simulator. Methods: Single‐blinded, prospective, proof‐of‐concept study conducted in a simulation operative suite. A simulator was developed through segmentation of source images and multi‐material 3D printing. Subjects were asked to point to seven anatomical sites before and after a short anatomy presentation of a human middle ear photograph. They also filled out a survey about the feasibility of the model. Outcome variables included survey scores, pre‐anatomy lesson (PreAL) and post‐anatomy lesson (PostAL) quiz scores. Results: There were 24 participants (19 residents, 1 fellow, and 4 attendings), none with self‐reported proficiency in EES. The PreAL mean score was 4.42 and PostAL quiz mean score was 5.32 (average improvement of 43% [CI = 17%–70%]; p =.003). The higher the level of training, the higher the PreAL scores (0.55 points per year of training; p =.004). The subspecialty (otology, other, in‐training) was also associated with the PreAL scores (p =.004). Total survey score means were 22.8 (out of 30). Conclusion: The results of our study suggest that our model has adequate anatomical high fidelity to mimic a real, pediatric temporal bone for EES. As 3D printing technologies continue to advance, the quality of ear models has the potential to provide improved surgical training for pediatric EES. Level of Evidence: 4 [ABSTRACT FROM AUTHOR]

Objective: Respiratory epithelial adenomatoid hamartoma (REAH) is classified as a histopathologic diagnosis and often identified in sinus surgery for chronic rhinosinusitis (CRS). The purpose of this study was to clarify the frequency and predictors of REAH and prognosis of CRS with REAH in CRS cases. Methods: In the first study, we histologically reviewed sinonasal polyps and mucosal tissue specimens obtained from patients who underwent endoscopic sinus surgery (ESS) for CRS to reveal how many REAH were involved in ESS cases. We compared REAH and non‐REAH groups in terms of preoperative symptoms and endoscopic, imaging and blood examination findings to elucidate predictors of REAH genesis. In the second study, we compared the data 3 months after surgery such as endoscopic and imaging findings and olfactory test to evaluate prognosis of CRS with REAH. Results: The prevalence of REAH was 15.5% of all 304 cases in the first and second studies combined. Higher polyp score in the middle meatus was an independent predictor of the presence of REAH (p =.02). Presence of REAH was significantly associated with the enlargement of olfactory cleft polyps (p <.01), increasing postoperative scores of standard olfactory tests (p =.03), and decline of ratio of improvement (p <.01) measured using T&T olfactometry. Conclusions: Higher polyp score in the middle meatus is an independent predictor of REAH. Olfactory function is difficult to recover after surgery in REAH patients because it is associated with recurrent polyps in the olfactory cleft. [ABSTRACT FROM AUTHOR]

Background: Woakes' disease is the eponymous name for severe chronic rhinosinusitis with nasal polyposis (CRSwNP) leading to thinning and expansion of the nasal pyramid. The endoscopic treatment of the sinus disease, while extensive, is standard practice for the rhinologist. Management of their external nasal deformities, for many, is not. Simultaneous closed rhinoplasty in these patients is straightforward, easy to perform and achieves an excellent esthetic outcome. Methods: Three patients with CRSwNP and notable nasal pyramid expansion are reviewed. All patients had eosinophilic disease, with two having NSAID‐exacerbated respiratory disease (N‐ERD). All three patients underwent full house endoscopic sinus surgery from May 2018 to September 2019 along with simultaneous closed rhinoplasty. Two of these patients required only external digital pressure to fracture the nasal bones for gentle Boies elevator repositioning, while the third had osteotomies with minimal force to aid reduction. Results: Postoperatively, patients had excellent nasal airway symptom improvement, and the cosmetic results following rhinoplasty demonstrated normalization of symmetry, profile, and contour of the nose with high‐patient satisfaction. Conclusion: Based on our experience, simultaneous rhinoplasty on the thinned nasal bones of Woakes' Disease patients is not only easy to perform, but provides excellent cosmetic and functional results by allowing bone to remodel in the appropriate position, and avoids a second‐stage rhinoplasty. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to find a utility of a newly developed 3D‐printed sinus model and to evaluate the educational benefit of simulation training with the models for functional endoscopic sinus surgery (FESS). Material and methods: Forty‐seven otolaryngologists were categorized as experts (board‐certified physicians with ≥200 experiences of FESS, n = 9), intermediates (board‐certified physicians with <200 experiences of FESS, n = 19), and novices (registrars, n = 19). They performed FESS simulation training on 3D‐printed models manufactured from DICOM images of computed tomography (CT) scan of real patients. Their surgical performance was assessed with the objective structured assessment of technical skills (OSATS) score and dissection quality evaluated radiologically with a postdissection CT scan. First we evaluated the face, content, and constructive values. Second we evaluated the educational benefit of the training. Ten novices underwent training (training group) and their outcomes were compared to the remaining novices without training (control group). The training group performed cadaveric FESS surgeries before and after the repetitive training. Results: The feedback from experts revealed high face and content value of the 3D‐printed models. Experts, intermediates, and novices demonstrated statistical differences in their OSATS scores (74.7 ± 3.6, 58.3 ± 10.1, and 43.1 ± 11.1, respectively, p <.001), and dissection quality (81.1 ± 13.1, 93.7 ± 15.1, and 126.4 ± 25.2, respectively, p <.001). The training group improved their OSATS score (41.1 ± 8.0 to 61.1 ± 6.9, p <.001) and dissection quality (122.1 ± 22.2 to 90.9 ± 10.3, p =.013), while the control group not. After training, 80% of novices with no prior FESS experiences completed surgeries on cadaver sinuses. Conclusion: Repeated training using the models revealed an initial learning curve in novices, which was confirmed in cadaveric mock FESS surgeries. Level of evidence: N/A [ABSTRACT FROM AUTHOR]

Background: This study aimed to evaluate the effect of local nasal desmopressin premedication on blood loss and the quality of surgical field in Functional Endoscopic Sinus Surgery (FESS). Material and methods: In a randomized clinical trial, patients referred for FESS to treat their bilateral chronic rhinosinusitis were recruited. The participants were adults (≥18 years). They were randomly assigned (1:1:1) to receive low‐dose (20 μg) or high‐dose (40 μg) intranasal desmopressin (DDAVP) or placebo 60 min before the induction of general anesthesia. Standard FESS was performed by the same surgeon. The primary outcomes were volume of intraoperative bleeding and the quality of surgical field. Clean surgical field was defined as a score ≤2 on the Boezaart grading system. Results: A total of 120 patients were included on an intention‐to‐treat basis (mean age: 41.0 years; 40 women, 80 men). There were no significant differences in primary outcomes between low‐dose DDAVP and placebo. As for the volume of blood loss, however, there was a significant difference between high‐dose DDAVP and placebo (mean difference: 29.6 ml; adjusted Cohen's d: −1.02; p <.001). Also, in the high‐dose DDAVP, the probability of having a good surgical field over time was about two times higher than in the placebo group (RRs for first and second surgical sides: 1.89 and 2.18). The number needed to treat for the two time points was 1.6 and 1.3, respectively. Conclusion: The present study showed that the use of desmopressin at a dose of 40 μg 1 h before surgery can reduce bleeding and improve the quality of the surgical field. Further studies are recommended to be able to generalize these findings to other ENT surgeries. Level of evidence: 1b. [ABSTRACT FROM AUTHOR]

Objective: To observe and summarize variations of the chorda tympani nerve to effectively protect it during surgery. Methods: Surgical videos of patients undergoing endoscopic ear surgery in the past 3 years were retrospectively observed to identify chorda tympani nerve variations. Results: In total, 237 cases were reviewed. The tympanic sulcus or annulus was the boundary between the posterior wall of the external auditory canal and chordal eminence (CE). The chorda tympani nerve was divided into three types: type I, the periannular segment was located medial to the CE and covered by the bony eminence (32.5%); type II, the periannular segment was located inferior to the CE, and the nerve did or did not contact the bony edge of the CE (62.0%); and type III, the periannular segment was located lateral to the CE and medial to the tympanic annulus, and the iter chorda posterius was located in the tympanic sulcus (5.5%). The rate of injury to the chorda tympani nerve was 2.5% of 237 cases. The location of the iter chorda posterius on preoperative computed tomography was highly reliable for prediction of type I and III nerves. Secondary exposure of the posterior canaliculus might occur in patients with external auditory canal cholesteatoma, who were specifically included in this study. Conclusion: CE‐based classification of the chorda tympani nerve can concisely describe variations of the chorda tympani nerve and provide guidance for neuroprotection during endoscopic ear surgery. Patients with external auditory canal cholesteatoma may have secondary exposure of the posterior canaliculus. Level of Evidence: NA. [ABSTRACT FROM AUTHOR]

Objective: Complete endoscopic radical resection of thyroid cancer, especially through the areolar approach, can achieve curative and acceptable cosmetic effects in patients with differentiated thyroid carcinoma. However, some inherent characteristics of endoscopic procedures hamper functional protection of the recurrent laryngeal nerve (RLN). Intraoperative neuromonitoring (IONM) is considered the most important accessory to protect the nerves during conventional radical thyroidectomy. This study aimed to evaluate the feasibility and necessity of IONM during complete endoscopic radical resection of thyroid cancer. Methods: A total of 106 patients with differentiated thyroid carcinoma were enrolled in the study between February 2013 and April 2018. Based on the use of the IONM technique, all patients were divided into the IONM (n = 54) and non‐IONM groups (n = 52). Overall, 66 RLNs were involved in the IONM group, and 61 RLNs were involved in the non‐IONM group. The time and ratio of RLN identification and the number of transient and permanent RLN injuries between both groups were compared. Results: Compared to the non‐IONM group, the IONM group required less time for RLN identification (3.05 ± 1.58 vs. 9.36 ± 4.82 min, p <.01). The ratio of RLN identification in the IONM group was much higher than that in the non‐IONM group (100.00% vs. 88.52%, p =.01). A significant difference was observed in RLN transient injury between the two groups (one case accounting for 1.51% in the IONM group vs. eight cases accounting for 13.11% in the non‐IONM group; p =.03). Conclusion: IONM significantly improved RLN identification and reduced transient RLN injuries during complete endoscopic radical resection. Level of Evidence: 3b. [ABSTRACT FROM AUTHOR]

Background: The advance of endoscopic surgery has enabled selective section of the postganglionic nerve branches from pterygopalatine ganglion (PPG) as a modification of the vidian neurectomy. Recent microanatomic studies have suggested that the nasal mucosa is also innervated by multiple efferent rami associated with the sphenopalatine artery (SPA) in the procedure "posterior nasal neurectomy." This anatomic cadaveric study aims to identify all postganglionic nerve fibers in the lateral nasal wall which should inform future surgical procedures aimed at interrupting these nerve fibers. Methods: Two cadaver heads, with a total of three individual sides, were dissected. All neurovascular structures penetrating the vertical plate of palatine bone were carefully identified following meticulous removal of the overlying mucosa layers. The efferent nerve fibers were identified and dissected back to their origin—the PPG or greater palatine nerve. Results: Several foramina with efferent PPG nerves were identified on the vertical plate of the palatine bone and medial pterygoid plate. The superior, middle, and inferior turbinates (IT) were innervated by efferent nerves from the PPG via the anterior region of the SPA. The IT was innervated from nerves originating from behind the SPA through bony foramina. The lateral wall of inferior meatus was innervated by efferent nerves that originated from greater palatine nerve and pharyngeal nerve. Conclusion: This study demonstrated the anatomical positions of the postganglionic nerves that innervate the lateral nasal wall. These nerves are located anterior to the SPA as well as posterior to the SPA, where they penetrate the palatine bone. Level of evidence: NA. [ABSTRACT FROM AUTHOR]

Objective: To report our experience on the complications of primary pediatric endoscopic sinus surgery (ESS). Methods: Case series of pediatric ESS performed from 1991 to 2016 on children who failed maximal medical therapy and/or adenoidectomy. Inclusion criteria were children (age <12 years old) who underwent primary ESS with or without adenoidectomy for chronic rhinosinusitis (CRS) after failed maximal medical therapy and/or adenoidectomy. All patients underwent maxillary antrostomy ± partial or total ethmoidectomy. Patients with complicated acute rhinosinusitis were excluded. Complications reviewed included: skull base injury and CSF leak, orbital injuries (blindness, orbital hemorrhage, emphysema, periorbital swelling and bruising, fat exposure), and bleeding requiring intervention. Results: A total of 352 patients underwent ESS between 1991 and 2016. There were no blindness or orbital hematoma reported, and no major nasal bleeding requiring intervention. The total number of complications was 31 (8.8%): 1 (0.3%) CSF leak, 3 (0.85%) orbital emphysema, 5 (1.4%) periorbital ecchymosis, and 22 (6.3%) lamina papyracea violation with orbital fat exposure. Conclusions: Complications of primary pediatric ESS can be rare dependent on surgeon's experience, the most common being orbital injury. Level of evidence: 4. [ABSTRACT FROM AUTHOR]

Background: High tissue and blood eosinophils are linked to poor treatment outcome in patients with chronic rhinosinusitis with nasal polyps (CRSwNP). However, the difference between the patients with different level of blood or tissue eosinophilia in relation to disease control is still lacking. Objectives: This study aimed to characterize patients with CRSwNP with intensely high eosinophil level. Methods: A retrospective study of CRSwNP patients underwent endoscopic sinus surgery was conducted. The patients were subdivided with various cut‐off values of blood and tissue eosinophils. Tissue eosinophils of ≥50% and 10%–20% were defined as intensely high tissue eosinophils (IH‐tissue‐eos) and high tissue eosinophils (H‐tissue‐eos), respectively. Blood eosinophils of ≥0.6 × 109/L and 0.2 × 109/L–0.3 × 109/L were defined as intensely high blood eosinophils (IH‐blood‐eos) and high blood eosinophils (H‐blood‐eos). Clinical characteristics, Lund‐Mackay score (LMS), and disease control status were compared between subgroups. Results: A total of 302 patients were enrolled. There was a trend toward a higher rate of uncontrolled disease when the patients subdivided by blood eosinophil cut‐off values ranged from 0.1 × 109/L to 0.6 × 109/L. The controlled patients accounted for 27%, 36%, 22%, and 31%, and the uncontrolled patients 46%, 32%, 52%, and 31% of patients in IH‐tissue‐eos, H‐tissue‐eos, IH‐blood‐eos, and H‐blood‐eos subgroup, respectively. The percentages of patients in the three categories of control were not significantly different between IH‐tissue‐eos and H‐tissue‐eos subgroups. By contrast, the IH‐blood‐eos subgroup had higher percentages of current smoker and asthma, preoperative LMS and tissue eosinophil percentage, and showed a trend toward a higher rate of uncontrolled subjects compare with the H‐blood‐eos subgroup. Conclusion: CRSwNP patients with IH‐blood‐eos (≥0.6 × 109/L) may be possibly associated with a poorer disease control than those with levels near the threshold of blood eosinophilia (0.2 × 109/L–0.3 × 109/L). Further larger, preferably prospective studies are needed to confirm this relationship. Level of Evidence: 4. [ABSTRACT FROM AUTHOR]

Background: More than a decade after its introduction, some rhinologic surgeons have incorporated the technique of balloon sinus dilation (BSD) technology into "hybrid" endoscopic sinus surgery (ESS) procedures. A novel BSD device which can be placed over standard surgical instruments, including surgical navigation instruments, has recently been introduced. We present a case series in which this device was used as a hydraulic dissection tool to aid safe efficient surgery in difficult‐to‐access locations of the paranasal sinuses during hybrid ESS procedures. Objective: Highlight the potential role of hydraulic dissection techniques during ESS utilizing BSD. Methods: Retrospective case series of patients who underwent ESS performed in part with a novel BSD device. Results: A total of 10 patients who underwent hybrid ESS with BSD were reviewed. In all 10 cases, the novel BSD device was used without complication. The device was used over straight and curved suctions while being tracked with surgical navigation in all cases. Thirteen posterior ethmoid dissections, 12 sphenoidotomies, and 8 frontal sinusotomies were assisted with the device. For the selected dissections in which the balloon was utilized, the operating surgeon found it to be helpful in creating more space in difficult to access areas which allowed for continued safe surgical dissection. Conclusions: Sinus balloon devices can be used as a hydraulic dissection tool and may be a useful adjunct during ESS. The novel dilation system used in this study, which deploys a sinus balloon device over standard surgical instruments with surgical navigation, provides even more opportunity to accurately dissect difficult areas of the paranasal sinuses safely and efficiently. Further studies evaluating the exact role of sinus balloon devices used as a hydraulic dissection tool during ESS are warranted. Level of Evidence: 4. [ABSTRACT FROM AUTHOR]

Objectives: To describe our experience with the use of postoperative antibiotics in the management of unilateral chronic rhinosinusitis (CRS) patients with active infection at the time of surgery, and to evaluate the need for routine postoperative antibiotic administration in this population. Methods: This retrospective chart review analyzed the medical records of all patients who underwent endoscopic sinus surgery for unilateral purulent CRS between November 2013 and September 2019 at a tertiary care center and who were not prescribed routine postoperative antibiotics. Duration of time until normalization of sinus cavities and whether antibiotics were ultimately prescribed for persistent infectious signs and symptoms were recorded. Patient characteristics and findings were analyzed to determine if any of the evaluated parameters were associated with the need for postoperative antibiotics. Results: Sixty‐nine patients were included in the study. Thirty‐three (47.8%) did not require antibiotics during the postoperative period. The average time to sinus normalization was 8.1 weeks (range 1‐24 weeks) for patients who received antibiotics and 5.7 weeks (range 1‐16 weeks) for those who did not receive antibiotics (P =.066). No evaluated variables were associated with antibiotic use on univariate or multivariate analysis. Conclusion: Postoperative antibiotics were not necessary to normalize infected sinus cavities for nearly half of patients with unilateral purulent CRS in this series. Further studies are needed to better delineate which patients would derive benefit from postoperative antibiotics. Level of Evidence: Level IV. [ABSTRACT FROM AUTHOR]

Objective: Assessment the effect of topical application of mitomycin‐C (MMC) after endoscopic removal of antrochoanal polyp (ACP) on its recurrence rate. Methods: This prospective study was done on patients with ACP. Endoscopic nasal surgery has been done to remove the polyp after wide middle meatal antrostomy. The patients were categorized into two groups. In MMC group, after endoscopic ACP removal, MMC on a piece of cotton was topically applied inside the maxillary antrum in the suspected site of ACP origin. A second group was used as a control group without MMC application. Results: The study included on 40 patients; 20 patients in each group. Topical MMA application was easily performed. No granulation, crust, infection, or bleeding was reported in all cases of both groups. Recurrent polyp was not reported in MMC group, while recurrent polyp was detected in four cases (20%) in control group without MMA application with statistically significant difference (P =.035). Conclusion: Topical MMC application inside the maxillary sinus after endoscopic removal of the ACP is safe, easy, and effective. Level of evidence: 2c. Patients with antrochoanal polyp (ACP) were categorized into Mitomycin‐C (MMC) group for whom MMC was topically applied inside the maxillary antrum after endoscopic ACP removal and a control group without MMC application.‐ the recurrent polyp was not reported in the MMC group and was detected in 20% of the control group with a statistically significant difference (P= 0.035).‐ so topical MMC application inside the maxillay sinus after endoscopic removal of the ACP could effectively decrease the recurrence. [ABSTRACT FROM AUTHOR]

Objectives: Recurrent laryngeal nerve (RLN) injury is one of the severe complications in thyroid surgery. Therefore, intraoperative nerve monitoring (IONM) has been widely used to identify the RLN and confirm its integrity. Recently, the usefulness of continuous IONM (CIONM) with automatic, periodic stimulation to the vagus nerve during thyroid surgery was reported. This study aimed to report our experience with minimally invasive video‐assisted endoscopic endocrine neck surgery (VANS), during which, CIONM was successfully applied for the first time. Methods: Consecutive patients who underwent thyroid surgery with CIONM, performed in our department using either external neck incision surgery or VANS between July 2017 and June 2019, were retrospectively analyzed. Results: A total of 22 patients who underwent thyroid surgery with neck incision (14 cases; 7 men and 7 women; age, 21‐75 years [mean, 52 years]) or VANS (8 cases; 8 women, age, 20‐61 years [mean, 41 years]) were enrolled in this study. The addition of CIONM in VANS prolonged the operation's duration by approximately 30 minutes as the endoscopic surgery was technically more difficult. No intra‐ and postoperative incidence of transient or permanent RLN palsy was observed in any patient, except for three patients who underwent external neck incision surgery in whom combined resection was unavoidable due to tumor invasion of the RLN. Conclusion: We reported the first successful application of CIONM during thyroidectomy using VANS. Future clinical trials should clarify the benefits of CIONM when compared to intermittent IONM in VANS. Level of Evidence: 5. [ABSTRACT FROM AUTHOR]

Objectives: Chronic rhinosinusitis (CRS) is a disease with significant impacts at both a societal and personal level. There has been an increase in emphasis on patient‐centered care and patient outcomes, with value becoming a commonplace concept in health care systems. This review seeks to better define the value that endoscopic sinus surgery (ESS) provides in the treatment of CRS. Data Sources: PubMed literature review. Review Methods: A review of published literature related to ESS and its effects on CRS patients from multiple perspectives (quality outcomes, patient satisfaction, cost‐effectiveness) was integrated and analyzed through the viewpoint of a value equation. Results: ESS provides long‐term quality outcomes in both patient‐reported outcome measures (PROMs) as well as in objective metrics for patients refractory to medical therapy. The vast majority undergoing ESS are satisfied both in the short and long‐term with their decision to pursue surgery. Treatment of CRS with ESS is generally more cost‐effective than continued medical therapy (CMT), especially in refractory patients. Taken together, the combination of improved outcomes as well as patient satisfaction after ESS in relation to the costs of surgery provides significant quantifiable value to CRS patients. Conclusion: ESS clearly provides value in the treatment of CRS. Understanding both quality and outcome metrics along with patient expectations and priorities will assist providers in generating a more personalized and value‐based approach to patients with CRS. Level of Evidence: 5. [ABSTRACT FROM AUTHOR]

Objectives: Pain and analgesic requirements after functional endoscopic sinus surgery (FESS) vary widely. This study aims to quantify pain after routine FESS and determine the most commonly used pain management regimen. Methods: Retrospective chart review of 100 patients who underwent FESS from Oct 2017 to May 2019. Patients prospectively completed a daily pain diary and reported pain levels that were categorized into no pain (0), mild (1‐3), moderate (4‐7), or severe (8‐10). Patients were categorized into narcotics, non‐narcotics, combination, or none based on type of analgesic used. Results: Sixty‐nine patients were included. Majority of patients reported either mild (39%) or no pain (28%) during the first 5 PODs. Mean POD1 pain score was 3.98, which decreased with each subsequent POD. On POD1, 37% used opioids (n = 37), 32% used non‐opioids (n = 32), 22% used a combination (n = 22), and 9% used no pain meds (n = 9). Mean number of narcotic pills used within the first 5 PODs was 2 pills on any given day. Age was inversely associated with reported POD1 pain scores (P =.003) and use of preoperative steroids in patients with sinonasal polyposis was associated with lower POD1 pain scores (P =.03). Conclusions: Even on POD1, majority of patients experienced either mild or no pain, and this decreases with each POD. Narcotics are grossly overprescribed and underutilized by patients postoperatively after FESS. We advocate for more judicious prescribing habits of narcotics by Otolaryngologists after FESS, and emphasize relying on non‐narcotic alternatives like Acetaminophen or NSAIDS to diminish narcotic use and abuse in the postoperative period. Level of Evidence: 4. [ABSTRACT FROM AUTHOR]

Objective: Techniques for reconstruction of skull base defects have advanced greatly since the introduction of the vascular pedicled nasoseptal flap in 2006. The objective of this review is to assess the current state of the field by examining both intranasal and extranasal techniques of vascular pedicled skull base defect repair, their indications and success rates, and novel techniques that are currently under investigation. Methods: A review of the literature describing the use of vascular pedicled flaps in skull base defect reconstruction was conducted using PubMed and Google Scholar. Results: The nasoseptal flap remains the most widely used vascular pedicled flap for endoscopic repair of skull base defects. Its ease of harvest, wide arch of rotation, and high success rates make it a popular choice among surgeons. Several variations including a "rescue" nasopseptal flap have been developed. Other less commonly used pedicled intranasal flaps include the middle turbinate flap and the posterior pedicled inferior turbinate flap. Additionally, several novel vascular pedicled flaps have been developed and tested in small cohorts of patients. Extranasal flaps such as the pericranial flap and the temporoparietal fascia flap are used less frequently than intranasal flaps. However, they remain valuable options for reconstruction in certain situations. Conclusion: Advancements continue to be made in the field of skull base defect reconstruction using vascular pedicled flaps. Though the nasoseptal flap remains the most widely utilized option, additional intranasal techniques continue to be developed and tested to optimize surgical outcomes and patient care. Level of Evidence: NA [ABSTRACT FROM AUTHOR]

Objectives: Frontal sinus surgery is considered one of the more challenging aspects of Functional Endoscopic Sinus Surgery, due to the complex variations in normal sinus anatomy but also increased morbidity due to the close proximity of critical structures such as the anterior cranial fossa and orbits. We aim to investigate the medial canthal point (MCP) as an anatomical landmark for safe frontal sinus access. Methods: The MCP intranasally is identified during surgery with non‐tooth forceps, with one limb just anterior to the medial canthus and the other intranasally in the same coronal plane along the skull base. This point was identified on 100 paranasal sinus computed tomography (CT) scan reconstructions. The distance between the anterior cranial fossa and MCP was measured on imaging—medial canthal point distance (MCPD). The maximal anterior‐posterior (AP) distance was measured on all scans. Results: The average MCPD for males was 13.0 mm (8.7‐20.4 mm) and for females 12.0 mm (6.8‐22.8 mm). Mean AP distance for males was 12.0 mm (4.5‐20.2 mm) and for females 10.4 mm (3.8‐15.9 mm). Mean distance for all 100 patients was 12.6 mm (range 7.5‐22.8 mm). In all cases, the MCP was anterior to the cranial fossa. Mixed effects modelling analysis showed a significant correlation between the MCPD and AP distance (P =.006). Conclusion: The MCP is a consistent anatomical landmark that can serve as an adjunct to safe frontal sinus access alongside the first olfactory fiber and CT navigation systems. However, patient selection continues to be very important, with larger well pneumatized frontal sinuses being ideal to tackle earlier in a surgeon's career. Level of evidence: NA [ABSTRACT FROM AUTHOR]

Objective: Endoscopic sinus surgery represents the gold standard for surgical treatment of chronic sinus diseases. Thereby, navigation systems can be of distinct use. In our study, we tested the recently developed KARL STORZ NAV1 SinusTracker navigation software that incorporates elements of augmented reality (AR) to provide a better preoperative planning and guidance during the surgical procedure. Methods: One hundred patients with chronic sinus disease were operated on using either a conventional navigation software (n = 52, non‐AR, control group) or a navigation software incorporating AR elements (n = 48, AR, intervention group). Incidence of postoperative complications, duration of surgery, surgeon‐reported benefit from the navigation system and patient‐reported postoperative rehabilitation were assessed. Results: The surgeons reported a higher benefit during surgery, used the navigation system for more surgical steps and spent longer time with preoperative image analysis when using the AR system as compared with the non‐AR system. No significant differences were seen in terms of postoperative complications, target registration error, operation time and postoperative rehabilitation. Conclusion: The AR enhanced navigation software shows a high acceptance by sinus surgeons in different stages of surgical training and offers potential benefits during surgery without affecting the duration of the operation or the incidence of postoperative complications. Level of evidence: 1b. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this article is to provide a state‐of‐the‐art review of the literature and summarize the latest publications on medical and surgical treatment of cystic fibrosis (CF) chronic rhinosinusitis (CRS), with an emphasis on describing recent advancements in cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapies. Methods: A comprehensive literature review was conducted utilizing the PubMed database with search phrases detailed within the body of the article. Abstracts were reviewed to include publications detailing medical, surgical, and CFTR modulating therapies for CF CRS. Findings from studies not previously reviewed and publications regarding CFTR modulators were emphasized. Results: No clear guidelines for treatment of CF CRS are available. Nasal saline rinses, topical steroids, topical antibiotics, and topical dornase alfa are reported medical therapies. Ivacaftor has some sinonasal symptomatic benefit. A new triple therapy CFTR modulator, elexacaftor/tezacaftor/ivacaftor, is capable of treating 90% of patients with CF and has shown the greatest FEV1 improvement of any CFTR modulator yet. There is no clear consensus on surgical indications or technique, though aggressive surgery in recalcitrant disease has shown some symptomatic benefit. Endoscopic sinus surgery after lung transplantation may benefit some patients in whom the sinuses serve as a reservoir for recurrent pulmonary infections by decreasing rates of bronchiolitis obliterans syndrome and improving 5 year survival. Conclusion: As lifespan increases for patients with CF, further investigation into medical therapy, CFTR modulator sinonasal outcomes, and surgical technique and outcomes for CF CRS is needed. Level of Evidence: 5. [ABSTRACT FROM AUTHOR]

Objectives: Aspirin‐exacerbated respiratory disease (AERD) is a chronic respiratory condition characterized by a triad of symptoms: asthma, chronic rhinosinusitis with nasal polyposis, and a respiratory reaction to aspirin and other cyclooxygenase‐1 inhibitors, also known as nonsteroidal anti‐inflammatory drugs. The objective of this review is to provide otolaryngologists with an overview of the pathophysiology, diagnosis, and treatment of this under‐recognized condition. Data sources and methods: Foundational papers on AERD were reviewed, focusing on the clinical otolaryngology and allergy/immunology literature and other high impact journals or trials. Results: AERD results from increased production of pro‐inflammatory leukotrienes and a decrease in production of anti‐inflammatory prostaglandins associated with the dysregulation of multiple enzymes influencing eicosanoid metabolism. Diagnosis hinges on a high index of suspicion, careful history, and confirmatory testing for all three elements. Treatments include endoscopic sinus surgery; topical, inhaled, or oral corticosteroids; aspirin desensitization; leukotriene modifying drugs; and the new class of biologics such as dupilumab. Conclusion: AERD is an under‐recognized disease associated with substantial patient‐reported morbidity. We expect rapid progress in the pathophysiological understanding of this disease and available treatments in the coming decades. Level of evidence: 5 [ABSTRACT FROM AUTHOR]

Background: As the number of endoscopic skull base surgeries has increased, postoperative changes in quality of life require attention, including evaluation of whether snoring symptoms change. Objective: To investigate the effect of endoscopic endonasal skull base surgery on snoring and nasal symptom scores. Methods: Between February 2009 and September 2018, 510 patients underwent skull base tumor resection via an endoscopic endonasal approach and were included in this study. Nasal symptoms were scored using the Nasal Obstruction Symptoms Evaluation (NOSE) scale and snoring symptoms were subjectively scored from 0 to 10 by partners using a visual analog scale (VAS). Computational fluid dynamics (CFD) was employed for pilot patient analysis. Results: A pituitary adenoma was the most common surgical pathology encountered over the past 10 years (81.6% of all tumors). The NOSE scores increased significantly after surgery (pre‐surgery, 3.28 ± 3.18; post‐surgery, 4.09 ± 3.61; P <.001). The snoring VAS score decreased significantly postoperatively (pre‐surgery, 2.91 ± 2.74; post‐surgery, 2.43 ± 2.45; P <.001). A positive correlation was apparent between the NOSE and snoring score changes (r = 0.374; P <.001). Conclusions: Snoring improved after endoscopic endonasal skull base surgery, associated with changes in nasal symptoms. Level of Evidence: 4. [ABSTRACT FROM AUTHOR]

Background: Multimodal perioperative analgesia including acetaminophen is recommended by current guidelines. The comparative efficacy of intravenous vs oral acetaminophen in sinus surgery is unknown. We aimed to determine whether intravenous or oral acetaminophen results in superior postoperative analgesia following sinus surgery. Methods: This was a prospective randomized trial with blinded endpoint assessments conducted at a single large academic medical center. Subjects undergoing functional endoscopic sinus surgery were randomized to intravenous vs oral acetaminophen in addition to standard anesthetic and surgical care. The primary outcome was visual analogue scale pain score at 1 hour postoperatively. Results: One hundred and ten adult patients were randomized; 9 were excluded from the data analysis. Fifty patients were assigned to intravenous acetaminophen and 51 to oral acetaminophen. Postoperative pain scores at 1 hour (primary endpoint) were not significantly different between the intravenous and oral acetaminophen groups. Similarly, there was no significant difference in pain scores at 24 hours postoperatively. Finally, there was no significant difference in postoperative opioid usage in the postanesthesia care unit or over the first 24 hours postoperatively. Conclusions: This is the first comparative efficacy trial of oral vs intravenous acetaminophen in sinus surgery. There was no significant difference in pain scores at 1 or 24 hours postoperatively, and no difference in postoperative opioid use. Intravenous acetaminophen offers no apparent advantage over oral acetaminophen in patients undergoing sinus surgery. Level of Evidence: 1b [ABSTRACT FROM AUTHOR]

Objective: Histopathology of the maxillary sinus mucosa with intractable odontogenic maxillary sinusitis (OMS) was investigated and the role endoscopic sinus surgery (ESS) plays in its pathophysiology was clarified. Study Design: Histopathological analysis of the OMS mucosa. Methods: Surgical specimens were obtained from 20 patients who underwent ESS for intractable OMS. For rigid endoscopic observation of the mucosae, a 70° rigid endoscope 4 mm in diameter with an attached high definition surgical camera was used. Histopathological analyses of the maxillary sinus mucosa were conducted by light and scanning electron microscopy. Results: All the maxillary sinuses were filled, not with viscous, but with purulent secretions. The high‐definition camera showed that the maxillary sinus mucosa had gyrus‐like appearance. Light microscopic histopathological studies revealed that the surface of the maxillary sinus mucosa was convoluted. Light and scanning electron microscopic histopathological studies revealed that the ciliated cells of the epithelium had not decreased and their goblet cells were not hypertrophic, indicating that the damage of the ciliated columnar epithelium was not severe and they were not injured irreversibly. Conclusion: The ciliated columnar epithelium with intractable OMS was not severely damaged and not irreversibly injured. Hence, the pathophysiology of intractable OMS is one of the reasons why ESS is highly indicated for maxillary sinusitis requiring surgery and the treatment results are exceptionally good when the ventilation and drainage of the maxillary sinus is successfully restored after surgery. Level of Evidence: NA [ABSTRACT FROM AUTHOR]

Background/Objective: Complicated acute rhinosinusitis in the pediatric population is an uncommon problem that may affect the orbit or brain and is life‐threatening. This condition requires surgical intervention with endoscopic sinus surgery for source control, and prior studies have demonstrated the safety of balloon sinuplasty in chronic frontal sinusitis. Methods/Results: We present our approach with a balloon sinus dilation hybrid procedure to resolve four distinct types of complicated acute frontal sinusitis in pediatric patients, including intracranial manifestations, intraorbital complications, and recurrent disease. All four patients were able to be managed operatively with frontal balloon sinuplasty. Conclusions: Prior efficacy has been demonstrated for chronic frontal sinusitis in the pediatric population. We demonstrate that frontal balloon sinuplasty is also feasible in the proper clinical setting for acute frontal sinusitis, even in the presence of regional complications or recurrent disease. Level of Evidence: 4 [ABSTRACT FROM AUTHOR]

Objective: The histopathological characteristics of primary vs recurrent nasal polyps in patients with chronic rhinosinusitis with nasal polyps (CRSwNP) have not been studied comprehensively. Identification of these features may be helpful for prognostication, postoperative management, and consideration of novel eosinophil‐targeting biologic therapy. This study investigates the histopathological differences in primary vs recurrent CRSwNP tissue. Methods: Patients undergoing endoscopic sinus surgery for CRSwNP were included if all 13 histopathological and mucin characteristics on a standardized report were available. Histopathology parameters were compared in surgical tissue and mucin from primary vs recurrent CRSwNP. Results: Complete structured histopathology reports were available for 96 patients (39 primary polyps and 57 recurrent polyps). Compared to primary polyp tissue, recurrent CRSwNP mucin was significantly more likely to feature eosinophil aggregates (57.9% vs 35.9%; P =.047). Tissue eosinophilia (using a threshold >10 per high power field [HPF]) was not significantly different in primary and recurrent CRSwNP tissue. Other histopathologic parameters and clinical characteristics were similar. Conclusion: Eosinophil aggregates on histopathology are significantly more likely to be present in recurrent CRSwNP. In the limited series, tissue eosinophilia (>10 per HPF) was not significantly different in primary and recurrent CRSwNP. Therefore, in addition to the study of tissue eosinophilia levels, Rhinologic surgeons should also direct attention to CRSwNP mucin. Mucin eosinophilic aggregates are an independent marker of severe inflammation that is associated more likely with recurrent vs primary polyposis. Further study of this marker may help determine its role of choice of postoperative medical therapies, including anti‐eosinophilic biologics. Level of Evidence: 4 [ABSTRACT FROM AUTHOR]

Objective: Osteoradionecrosis (ORN) of the sphenoid is a rare but potentially lethal complication that can occur after irradiation of nasopharyngeal and clival malignancies. The objective of this study was to describe a multimodal treatment strategy tailored to the clinical signs and to the radiological extent of the disease, and to report on its preliminary results. Methods: Retrospective monocentric study at a tertiary skull base center. Patients treated for a sphenoid ORN from January 2014 to August 2018 were identified and charts were retrospectively reviewed for demographics, histologic tumor type, previous treatments of the tumor, clinical signs at presentation, radiological data, treatment, and outcomes. Sphenoid ORN was treated by a combination of medical therapy, endovascular treatment, and/or surgery. The use of each of these therapeutic modalities was based on the extent of ORN and on the presenting signs. Results: Seven patients were included: four patients underwent endovascular treatment with occlusion of the internal carotid artery, five patients underwent surgical debridement, and covering of the exposed bone by a local flap, seven patients received antibiotics (in combination with pentoxyphilline, tocopherol, and clodronate in one case). Three patients died after progression of the ORN. The global survival rate was 57% (4/7) with a mean follow‐up of 24 months. In one case, ORN was treated successfully by medical treatment only, with a combination of antibiotics, pentoxyphilline, tocopherol, and clodronate. Conclusion: This retrospective study describes the results of a management strategy adapted to the extent of the disease in sphenoid ORN and based on medical therapy only, or on a combination of medical therapy, interventional radiology, and/or surgery. Level of evidence: 4 [ABSTRACT FROM AUTHOR]

Objectives: Structured histopathology reporting has been recently described for detailing immunopathological characteristics of chronic rhinosinusitis (CRS), and can be utilized for subtyping CRS and personalizing management. This study scrutinized elements of structured histopathology to identify characteristics that prognosticate outcomes following endoscopic sinus surgery (ESS) for CRS patients with nasal polyps (CRSwNP) and without nasal polyps (CRSsNP). Methods: Outcomes following ESS were measured using the patient‐reported 22‐item sinonasal outcome test (SNOT‐22). Changes in total SNOT‐22 scores at 6 and 12 months postoperatively were analyzed. Thirteen parameters reported in structured histopathology of sinus surgical tissue were studied for association with outcomes postsurgery. The overall cohort of all CRS patients was studied, along with subgroup analyses of CRSwNP and CRSsNP patients. Results: In the entire CRS cohort (n = 171), eosinophil count >10 per high power field (HPF) was associated with greater improvement in SNOT‐22 scores at 6 months post‐ESS (P =.039). At 12 months follow‐up, no histopathological characteristic was associated with change in total SNOT‐22 score. In the CRSwNP (n = 66) subgroup, the presence of fibrosis (P =.006) and eosinophil count ≤10 per HPF (P =.025) were associated with less favorable changes in SNOT‐22 scores at 12 months follow‐up. Fibrosis remained statistically significant in multivariable analysis (P =.007). Conclusions: At 6 months post‐ESS, tissue eosinophilia is associated with significantly higher improvement in SNOT‐22 scores, but this difference is diluted by 12 months. Fibrosis was associated with less favorable outcomes in SNOT‐22 scores for CRSwNP patients at 12 months and may be a prognosticator for poorer long‐term outcomes. Level of Evidence: 4 [ABSTRACT FROM AUTHOR]

Objective: To provide an overview of Endoscopic Ear Surgery, its development, principles, and penetration in otology practice in 2018. Data Source: PubMed review of literature and cross‐sectional email survey of otologists. Methods: We reviewed all PubMed published articles on use of endoscopy in practice of otology over the last 50 years. Articles were categorized based on date of publication and pattern of utilizing the endoscope. We also conducted two identical email surveys in 2010 and 2018 of otologists on the use of endoscope and tabulated and compared results. Results: The number of publications on use of endoscope has increased from 6 in 1990 to an accumulated total of 451 in 2018. There has been a clear shift in the area of interest away from diagnostic endoscopy, to endoscope‐assisted surgery, and lately, to transcanal endoscopic ear surgery (TEES). Survey results further documented the increased awareness of the value of the endoscope and its increased use in clinical practice. Conclusion: TEES has gained traction as a subject of research interest and in clinical practice and has lately dominated the discussion on the use of endoscope in otology. Level of Evidence: NA [ABSTRACT FROM AUTHOR]

Objective: The narrative operative report (NR) bears testimony to critical elements of patient care. Residents' NRs also provide insights into their comprehension of the procedure. NR documentation is an informal element of surgical residency training but data regarding quality of such training are scant. We aim to evaluate the NR within a residency training program. Methods: The quality of NRs for endoscopic sinus surgery (ESS) was evaluated through a retrospective analysis of 90 NRs for ESS. Thirty‐four elements that the attending surgeon regards as "critical" variables, or quality indicators (QIs), that should be documented, were studied to evaluate quality. A "performance metric (PM)," defined as the average percent of QIs dictated/total word count, was determined. Subgroup analysis by the level of training was additionally performed. Results: Surgical indications, procedural steps, and immediate postoperative findings were accurately documented in 71%, 84%, and 82% of patients, respectively. The attending surgeon had the highest proportion of included key elements (89% ± 6.2%) followed by junior residents (87% ± 5.7%) and then senior residents (80% ± 14%) (P = .008). The attending surgeon also demonstrated the highest PM, followed by senior and then junior residents (P < .0001). Conclusions: The quality of NRs was found to be high overall, but not "perfect" for either the attending or trainee surgeon. The PM among residents was expectedly lower than the attending surgeon. We propose that a synoptic reporting system that ensures inclusion of key elements may be helpful in training residents (and attendings) in creating comprehensive and efficient NRs. Level of Evidence: 3 [ABSTRACT FROM AUTHOR]

Objectives: To assess the safety and effectiveness of in‐office bipolar radiofrequency treatment of nasal valve obstruction Study Design: Prospective, nonrandomized, multicenter case series Methods: Adult patients with a Nasal Obstruction Symptom Evaluation scale (NOSE) score ≥60 were selected. Patients were clinically diagnosed with dynamic or static internal nasal valve obstruction as primary or significant contributor to obstruction and were required to have a positive response to nasal mechanical dilators or lateralization maneuvers. Bilateral radio‐frequency treatment was applied intranasally using a novel device, under local anesthesia in a single session. Safety and tolerance were assessed by event reporting, inspection, and Visual Analogue Scale (VAS) for pain. Efficacy was determined using the NOSE score and patient‐reported satisfaction survey at 26 weeks. Results: Fifty patients were treated. No device or procedure‐related serious adverse events occurred. Soreness, edema, and crusting resolved by 1 month. The mean baseline NOSE score was 79.9 (SD 10.8, range 60–100), and all had severe or extreme obstruction. At 26 weeks, mean NOSE score was 69% lower at 24.7 (P <.0001) with 95% two‐sided confidence intervals 48.5 to 61.1 for decrease. The decrease in NOSE score did not differ significantly between patients who did or did not have prior nasal surgery. Patient satisfaction mean by survey was 8.2 of 10. Conclusion: In office treatment of internal nasal valve obstruction using a bipolar radiofrequency device is safe and well‐tolerated. Nasal obstruction, as assessed using the NOSE questionnaire at 26 weeks, was markedly improved with high patient satisfaction. Level of Evidence: 2b, prospective cohort [ABSTRACT FROM AUTHOR]

Objective: To construct a comprehensive picture of the typical chronic rhinosinusitis (CRS) patient in the United States including the demographics, comorbidities, and geographic prevalence. The study will also identify the diagnostic and treatment regimens, their cost, and pattern of use for both medically and surgically managed patients. Study Design: Historical cohort study utilizing private and public payer databases. Methods: Medical claims data from the Truven Health MarketScan Research Databases from the years 2010 to 2012 for patients with acute rhinosinusitis (ARS) and CRS 18 and older were analyzed. Results: There were 54 million unique patients in the databases from 2010 to 2012. Approximately 8 million had at least one diagnosis of ARS and 298,337 had a diagnosis of CRS. Females represented 63.7% of patients with ARS and 59.4% with CRS. Medicare patients represented 6.7% of the ARS population and 10.2% of the CRS population. The mean cost of a CRS episode for those commercially insured was $1024 and $762 in Medicare. CRS patients underwent diagnostic procedures including diagnostic endoscopy (55.1%), cultures (23.6%), sinus CT scan (82.1%) and MRI (0.2%). Endoscopic sinus surgery (ESS) was performed on 14.4% of those patients with CRS. Change in frequency of medication use from the 6 months prior to ESS to the 6 months post‐ESS yielded a reduction in total costs of 34.2% or $3.9 M. The most commonly operated sinuses (with or without septoplasty on same day as ESS) were the maxillary (94%/76.1%); followed by ethmoid (82.1%/66.6%); frontal (38.8%/35.1%); and sphenoid (28.5%/28.1%). In total, 16.6% had one sinus operated on, 39.1% had two, 24.6% had three, and 18.7% had four sinuses operated on. Conclusions: This data paints a much clearer understanding of the current medical and surgical management. This study confirms the previously described "value proposition" for the surgical management of those CRS patients refractory to medical management. Level of Evidence: 4 [ABSTRACT FROM AUTHOR]

Objective: To develop a hierarchical task listing of steps required to perform successful Functional Endoscopic Sinus Surgery (FESS). To complete a technical and human factor analysis of tasks resulting in the identification of errors, frequency of occurrence, severity, and reduction through remediation. Methods: A triangulation of methods was used in order to derive the steps required to complete a FESS: 1) a literature review was carried out of published descriptions of FESS techniques; 2) observations of three FESS; 3) interviews with surgeons on FESS techniques. Data sets were combined to develop a task analysis of a correct approach to conducting FESS. A review by 12 surgeons, and observation of 25 FESS resulted in refinement of the task analysis. With input from five consultant surgeons and one consultant anesthetist, a Systematic Human Error Reduction and Prediction Approach (SHERPA) was used to identify the risks and mitigating steps in FESS. Results: Ten tasks and 49 subtasks required for a correct approach to completing FESS were identified based on literature review and expert consensus. A risk score for each subtask was calculated from a suitable risk matrix. Risk reduction methods at each subtask were detailed. High‐scoring subtasks were evaluated and varying strategies examined to reduce the likelihood and mitigate the impact of error. The study demonstrates the usefulness of the HTA and SHERPA approach in standardization and optimization of clinical practice in order to improve patient safety. Conclusion: Hierarchical Task Analysis and SHERPA are valuable tools to deconstruct expert performance and to highlight potential errors in FESS. The HTA and SHERPA approach to surgical procedures are useful learning and assessment tools for novice surgeons. The information derived offers the opportunity to improve surgical training and enhance patient safety by identifying high‐risk steps in the procedure, and how risk can be mitigated. Level of Evidence: 2c Outcomes Research [ABSTRACT FROM AUTHOR]

Background/Objectives: Endoscopic surgery has a distinct disadvantage compared to direct vision: loss of binocular vision. Three‐dimensional endoscopy has been welcomed due to the promise of improving stereopsis. Methods: Prospective randomized study of junior doctors with minimal endoscopic experience, using both two‐dimensional and three‐dimensional, zero‐degree, 4‐mm Storz endoscopes. Data was collected using validated, standardized training models, both objectively and subjectively. Paired comparisons between variables relating to the endoscopes were performed using Wilcoxon's tests. Operators were then split into groups based on their endoscope preference, with comparisons made using Mann‐Whitney tests for Likert scale responses, Kendall's tau for ordinal variables, and Fisher's exact tests for nominal variables. Results: Reduction of field of vision of three‐dimensional endoscopy by 2%. Significant findings included decreased past‐pointing, improved depth and perception and image quality. Conclusion: The use of an endoscopic endonasal approach with three‐dimensional technology has measurable advantages for novice users, and highlights potential tailoring of future surgical training Level of Evidence: 1b [ABSTRACT FROM AUTHOR]

Objectives: The robotic retroauricular approach and transoral endoscopic thyroidectomy vestibular approach (TOETVA) have been employed to avoid anterior neck scarring in thyroidectomy with good success. However, outcomes have yet to be compared between techniques. We compare our initial clinical experience with these approaches for thyroid lobectomy at our institution. Methods: A review of initial consecutive patients who underwent robotic facelift thyroidectomy (RFT) (August 2011–August 2016) at our institution was conducted. This was compared with the same number of initial consecutive patients who underwent TOETVA (September 2016–September 2017) at our institution. Demographics, operative time, pathology, complications, and learning curve were compared between cohorts. Learning curve was defined based on the slope of linear regression models of operative time versus case number. Results: There were 20 patients in each cohort. There was no statistically significant difference in demographic data between cohorts. One hundred percent of RFT cases versus 95% TOETVA cases (P = .999) were completed without conversion to standard open technique with median operative times of 201 (124–293) minutes versus 188 (89–343) minutes with RFT and TOETVA, respectively (P = .36). There was no incidence of permanent recurrent laryngeal nerve injury in either cohort. The slopes of the regression models were 0.29 versus −8.32 (P = .005) for RFT and TOETVA, respectively. Conclusion: RFT and TOETVA are safe and feasible options for patients motivated to avoid an anterior neck scar. However, the quicker learning curve without the need for a costly robotic system may make TOETVA the preferred technique for institutions wishing to perform anterior cervical incision‐sparing thyroidectomy. Level of Evidence: 4 [ABSTRACT FROM AUTHOR]

Objective: To assess the usefulness of modified esophagogastroduodenoscopy (EGD) for the detection of second primary malignancies of the esophagus or hypopharynx in patients with oral squamous cell carcinoma and determine the association between the oral lesion subsite and esophageal or hypopharyngeal lesion occurrence. Study Design: Retrospective review. Methods: In total, 166 patients with oral squamous cell carcinoma without any established symptoms of esophageal or hypopharyngeal squamous cell carcinoma underwent modified EGD based on the Valsalva maneuver and U‐turn method, image‐enhanced endoscopy, and chromoendoscopy using Lugol's iodine for diagnosis. All suspected lesions were biopsied to determine the clinical stages and duplication rates. Odds ratios for the occurrence of duplicate lesions according to the oral lesion subsite were determined. Results: In total, 37 esophageal and 16 hypopharyngeal lesions were detected. According to the Union for International Cancer Control/American Joint Committee on Cancer classification (2009), 75.7% and 5.4% esophageal lesions were classified as stage IA and IB, respectively, and 50% and 18.8% hypopharyngeal lesions as stage II and stage I, respectively. Approximately 59.1% and 50% esophageal and hypopharyngeal lesions, respectively, were successfully treated by endoscopic resection. Oral lesions involving the floor of the mouth were more frequently accompanied by second primary malignancies of the esophagus or hypopharynx. Conclusions: Modified EGD is an effective noninvasive technique for early diagnosis and treatment of second primary malignancies of the esophagus and hypopharynx in patients with oral squamous cell carcinoma. In particular, patients with floor of the mouth lesions need close monitoring for hypopharyngeal and esophageal lesions. Level of Evidence: 3b. [ABSTRACT FROM AUTHOR]

Background: Endoscopic Modified Lothrop Procedure (EMLP) has become a fundamental practice in rhinology. Improvements in symptom burden, ostial patency, morbidity, and costs have surpassed that of an open approach to the frontal sinus. Long‐term efficacy has not been well established. Objective: This study details the long‐term outcomes of EMLP and risk factors for subsequent surgical revision at a single institution. Methods: This study utilized a retrospective review of patients who underwent EMLP from September 2006 to February 2017 by a single surgeon at an academic tertiary referral center. Patient demographics, indications, symptom burden, and endoscopic assessment of frontal ostium patency were analyzed for their effect on surgical outcome. Risk factors for failures were identified. Results: Seventy‐six consecutive patients with an average age of 58.1 years met the inclusion and exclusion criteria and underwent EMLP for chronic rhinosinusitis (CRS, 59%), neoplasm (26%), and mucoceles (15%). The average number of standard endoscopic sinus surgeries prior to EMLP was 2.9. The mean follow‐up of the cohort was 34.8 months, at the end of which, EMLP was successful in 78% of all patients, requiring no further surgery. Ninety percent of patients reported significant clinical improvement at the most recent follow‐up. Subgroup analysis of CRS patients revealed an equally high success rate but a higher likelihood of ostial closure. Recurrent disease necessitated revision endoscopic surgery in 17 patients, the majority of whom suffered CRS. Only tissue eosinophilia was identified to significantly increase the risk of revision surgery. Conclusions: The majority of the patients who undergo EMLP achieve sustained patency of the frontal sinus outflow tract and adequate symptom improvement. Prominent tissue eosinophilia identifies patients at risk of requiring additional frontal sinus surgery. Level of Evidence: 4. [ABSTRACT FROM AUTHOR]

Objective: Thyroid orbitopathy is a poorly understood extrathyroidal manifestation of Graves' disease that can cause disfiguring proptosis and vision loss. Orbital decompression surgery for Graves' orbitopathy (GO) can address both cosmetic and visual sequelae of this autoimmune condition. Endonasal endoscopic orbital decompression provides unmatched visualization and access to inferomedial orbital wall and orbital apex. This review examines the state of the art approaches employed in endonasal endoscopic orbital decompression for GO. Methods: Review of literature evaluating novel surgical maneuvers for GO. Results: Studies examining the efficacy of endonasal endoscopic orbital decompression are heterogenous and retrospective in design; however, they reveal this approach to be a safe and effective technique in the management of GO. Conclusion: Subtle variations in endoscopic techniques significantly affect postsurgical outcomes and can be tailored to the specific clinical indication in GO making endonasal endoscopic decompression the most versatile approach available. Level of Evidence: NA. [ABSTRACT FROM AUTHOR]