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Objective: To explore surgical technique and outcomes of revision endoscopic sinus surgery (ESS) in patients with previously repaired cerebrospinal fluid (CSF) leaks., Design: A case series of 13 patients with previously repaired iatrogenic CSF leaks who underwent revision ESS for recurrent sinus disease; a review of the preoperative workup, intraoperative findings, and postoperative outcomes., Setting: Two academic medical centers., Patients: Patients were included if they had a history of previously repaired skull base defect and iatrogenic CSF leak in the vicinity of the planned revision ESS., Interventions: Revision ESS was performed in the vicinity of the previously repaired CSF leak. Dissection was carefully performed to avoid a recurrent CSF leak., Main Outcome Measures: Preoperative workup, intraoperative findings, surgical technique, and complications were reviewed., Results: The study population consisted of 7 men and 6 women. Surgical navigation was used for all cases. Intrathecal fluorescein was not used in any case. In no instances was an active preexisting CSF leak identified or a new leak created. No minor or major postoperative complications arose in any of the study patients. All patients were discharged home within 24 hours. The mean (SD) follow-up was 26.0 (16.7) months., Conclusions: Previous skull base injury with CSF leak is not a contraindication to revision ESS. Safe ESS in this setting can be performed and may be recommended to such patients with symptomatic recurrence of their sinus disease.

Objective: To determine the efficacy of endoscopic optic nerve decompression for the treatment of patients with nontraumatic optic neuropathy., Design: Retrospective case series., Setting: Academic medical center., Patients: Ten optic nerve decompressions were performed on 7 patients with nontraumatic optic neuropathy caused by various pathologic entities, including meningioma, lymphangioma, fibro-osseous lesions (fibrous dysplasia and osteoma), mucopyocele, and Graves orbitopathy., Interventions: Endoscopic instrumentation was used in a transnasal fashion to decompress the optic nerve., Main Outcome Measures: Visual acuity and complication rates., Results: Mean visual acuity improved from 20/300 preoperatively to 20/30 after surgery. Visual acuity improved by at least 2 lines on the Snellen chart following 7 of the 10 decompressions. Median operative time was 133 minutes, and median length of stay was less than 24 hours. Complications were limited to postoperative hyponatremia and corneal abrasions, both of which resolved with conservative therapy. Mean follow-up time was 6.1 months., Conclusion: Endoscopic optic nerve decompression appears to be an effective treatment for restoring visual acuity in select patients who present with compressive optic neuropathy.

Objective: To determine the efficacy of frontal sinus drillout surgery for the treatment of chronic frontal sinusitis., Design: Retrospective case-control study. Mean +/- SD follow-up was 4.1 +/- 1.53 years (range, 1.4-6.9 years)., Setting: Academic medical center., Patients: One hundred consecutive patients with chronic sinusitis who underwent frontal sinus drillout surgery. Indications were failed previous frontal sinusotomy (n = 88) and frontal sinus mucocele (n = 12)., Interventions: Endoscopic removal of the floor of the frontal sinus (unilateral, n = 34; bilateral, n = 66) with a surgical drill. An intraoperative image-guidance system was used in 65 patients., Main Outcome Measures: Frontal sinus patency and improvement of symptoms associated with frontal sinusitis., Results: Frontal sinus patency with control of symptoms was achieved in 80% of patients. There were no intraoperative complications. Postoperative epistaxis occurred in 4% of patients. Of the 20 patients who developed restenosis of the frontal sinus ostium, 11 underwent revision frontal sinus drillout and 9 proceeded to frontal sinus obliteration. The success rate was comparable for the image-guidance and non-image-guidance groups (83.1% vs 74.3%, respectively; P =.56)., Conclusions: Frontal sinus drillout performed with or without an image-guidance system appears to be a safe and effective surgery for the treatment of patients with advanced disease of the frontal sinus. This procedure provides a reasonable alternative to frontal sinus obliteration, which remains a treatment option for patients who fail frontal drillout.

Objective: To ascertain the reliability of a proposed method for quantifying tissue eosinophilia in sinus mucosa., Design: Prospective cohort study., Interventions and Outcome Measures: Pathology slides from patients undergoing endoscopic sinus surgery for chronic rhinosinusitis were independently assessed by 2 reviewers. Using a proposed systematic counting method, the degree of tissue eosinophilia was quantified. Disease severity was assessed by computed tomographic (CT) staging. Intrarater, interrater, and intrapatient reliability was determined using correlational reliability analysis. The degree of correlation between tissue eosinophilia and CT stage was determined., Results: One hundred thirty-two slides from 65 patients were reviewed. The mean (SD) eosinophil density was 23.4 (37.2) eosinophils per high-power field. Only 12 patients (18%) had no eosinophils on histopathologic analysis. Strong intrarater (r> or =0.91 for each rater, P<.001) and interrater reliability (r> or =0.82 between raters, P<.001) was noted for the quantification method. A moderate degree of correlation was found between CT scan stage and degree of tissue eosinophilia (Spearman rho = 0.62, P<.001)., Conclusions: The proposed method for quantifying tissue eosinophilia in sinus mucosa is reliable and valid. A relatively strong correlation exists between CT scan stage and tissue eosinophilia in chronic rhinosinusitis.

Background: Although image-guidance systems have gained widespread acceptance for neurosurgical procedures, their role for extracranial surgery of the head and neck is yet to be defined., Objectives: To describe the authors' experience with image-guidance systems and to measure the effects of image-guided technology on the performance of minimally invasive otolaryngological procedures., Design: Prospective cohort study., Methods: Optical- and electromagnetic-based image-guidance systems were used during the performance of endoscopic surgery on patients with disease of the paranasal sinuses, orbit, skull base, and temporal bone (n = 79). Results were compared with those in control patients who underwent similar surgery without image guidance during the same period (n = 42)., Results: Intraoperative anatomical localization was accurate to within 2 mm at the start of surgery in all cases. Accuracy degraded by 0.89 +/- 0.20 mm (mean +/- SE) during the operative procedure. The use of an image-guidance system increased operating room time by a mean of 17.4 minutes per case (image-guidance group, 137.3 +/- 6.0 minutes [mean +/- SE]; control group, 119.9 +/- 5.7 minutes; P=.006) and increased hospital charges by approximately $496 per case. Intraoperative blood loss (image-guidance group, 178.4 +/- 18.0 mL [mean +/- SE]; control group, 149.4 +/- 20.1 mL) and complication rates (image-guidance group, 2.7%; control group, 4.7%) did not differ significantly between groups., Conclusions: Image-guidance systems can provide the head and neck surgeon with accurate information regarding anatomical localization in cases with poor surgical landmarks caused by extensive disease or prior surgery; however, the use of such systems is associated with increased operative time and expense.

Objective: To determine the efficacy of endoscopic surgery for chronic frontal sinusitis., Design: A prospective analysis of established measures of clinical outcome (Chronic Sinusitis Survey and Short Form 36) that was administered to patients before frontal sinus surgery and at intervals of 3 months, 6 months, and 1 year after surgery., Interventions: For limited disease, the frontal recess was opened and the frontal ostium probed or enlarged. For more severe cases, a drill was used to resect the frontal sinus floor and interfrontal septum., Setting: Private and institutional-based practices at an academic medical center., Subjects: Eighty-seven patients who underwent endoscopic surgery for frontal sinusitis, including 24 patients with severe disease who underwent a frontal sinus drillout procedure., Main Outcome Measures: Scores on the Chronic Sinusitis Survey, Short Form 36, and surgical revision rate., Results: Significant improvement in facial pain, nasal drainage, and congestion was observed 1 year after surgery (P<.01). Medication use was also significantly reduced during this period (P<.01). Quality-of-life measures showed greatest improvement in the domain of social functioning (P<.05). Three (12.5%) of 24 patients who underwent a frontal sinus drillout procedure did not respond to surgery secondary to restenosis of the frontal ostium., Conclusions: Although the long-term results of endoscopic surgery for frontal sinusitis are unknown, this approach appears to be effective for most patients and may provide a reasonable alternative to frontal sinus obliteration surgery in selected cases.

Objective: To determine the effects of sinus surgery on the production and perception of speech., Design: Vocal recordings were performed before, 1 week after, and at least 1 month after sinus surgery. Acoustic spectra were analyzed for nasal consonants /m/ and /n/, nasalized vowels, and nonnasalized vowels. Results for nasal consonants were compared with similar recordings obtained from a group of normal subjects with no history of sinus disease. Perceptual analysis of nasalized vowels was conducted by trained phoneticians., Setting: Private practice at an academic medical center., Subjects: Five patients who underwent endoscopic sinus surgery and 3 normal subjects., Main Outcome Measures: The spectral characteristics and perceptual attributes of nasal sounds., Results: Significant differences in spectral properties were observed for the consonants and nasalized vowels recorded before and after surgery (P < .001). Perceptual experiments for nasalized vowels demonstrated a postoperative decrease in nasality for the high vowel /i/, as in "beep," and an increase in nasality for the non-high vowel /ae/, as in "bad." These perceived changes correlated well with acoustic measures of nasal peak amplitudes and the lowest resonance peak amplitude of the vocal tract., Conclusions: Sinus surgery results in measurable effects on the produced acoustic signal and the perceived nasality of a patient's speech. The identified acoustic correlates may be useful for preoperative counseling of patients concerning expected changes in speech quality following surgery.

In chylous fistulas following radical neck dissections, we have found reexploration to be unrewarding, with infrequent identification of a specific leakage site intraoperatively and persistent fluid accumulation postoperatively. As an alternative, we injected tetracycline hydrochloride into the supraclavicular wound bed. This procedure resulted in a rapid, sustained decline in fistula output in two of three cases, avoiding surgical intervention. Tetracycline sclerotherapy has been described for treatment of intrathoracic and other intracavitary fluid collections. We believe that tetracycline sclerotherapy is an effective adjunct in the management of chylous fistulas following radical neck dissections and that this therapy should be attempted before surgical reexploration.