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Background: The potential reservoir of severe acute respiratory syndrome coronavirus (SARS-CoV-2) in the nasopharynxand upper airway of infected or asymptomatic patients undergoing endonasal procedures amid the ongoing coronavirusdisease 2019 (COVID-19) pandemic may put skull base surgeons and their teams at high risk of exposure to aerosolizedviral particles during endonasal procedures. Strategies to mitigate the risk of potential aerosol-generating procedures(AGPs) have been promoted at a feverish pace, and significant effort has been made to optimize guidelines limitingaerosolization. This review summarizes the use of topical therapies as a perioperative infection control strategy, detailingefficacy, safety, and delivery options. Methods: A PubMed/MEDLINE and Scopus database review of articles was conducted querying topical therapies, includingpovidone-iodine (PVP-I), chlorhexidine, saline, surfactants, alcohols, and interferon activity against coronaviruses, andsafety for peri-operative use. Results: Few clinical studies specifically investigate the in vivo viricidal activity of topical agents against SARS-CoV-2 in theperioperative setting. Of topical agents with viricidal potential, PVP-I is supported by the most robust investigations-invitro studies have shown that PVP-I solutions as low as 0.5% can completely inactivate SARS-CoV-2 with 15 seconds ofcontact time, and solutions as low as 0.23% may neutralize SARS-CoV-2 homologues. Regarding safety, PVP-Iconcentrations of 2.5% and greater are associated with ciliotoxicity effects on human respiratory epithelial cells, but can betolerated up to 5% when administered intraorally, and up to 1% as a sinus irrigation formulation. As for other agents,preliminary studies show that chlorhexidine mouthwash may transiently decrease the SARS-CoV-2 virus load below thedetectable limit in saliva for 2 to 4 hours, but in isolation it is less effective than PVP-I in vitro studies. Furthermore,chlorhexidine and other antiseptics including ethanol have a worse safety profile than PVP-I, including increasedflammability and ototoxicity. Studies also show that hypertonic saline nasal irrigation and gargling leads to decreasedduration of illness, transmission, and viral shedding among patients with the common cold, including coronaviruses, andwas well tolerated barring some reports of nasal irritation, epistaxis, and headache. Conclusions: Several topical therapies, including PVP-I and hypertonic saline, may be at least temporarily effective atinactivating SARS-CoV-2 in the perioperative setting. However, these interventions are not without potential risks, includingciliotoxicity, which adversely impacts the mucociliary clearance of pathogens, and the efficacy of these agents is limited byavailable clinical data. However, thoughtful, evidence-based approaches should be considered as a sustainable option toreduce the risk of respiratory viral particle aerosolization in AGPs, such as endonasal skull base surgery.

Objectives Examine the postoperative growth rate of residual juvenile angiofibroma (JA) in a large series of patients relative to pediatric growth parameters and other prognostic factors. Establish an algorithm for postoperative surveillance of patients with JA. Design Retrospective case series. Setting Tertiary referral academic center. Participants Pediatric patients undergoing surgical resection of JA between September 2005 and June 2015. Main Outcome Measures Postoperative recurrence and tumor growth rates. Results Thirty-eight patients were identified with a mean follow-up of 24.1 months. Sixty-eight percent (26/34) of patients achieved gross total resection, and 32% (12/38) had persistent postoperative disease. Of those with postoperative residual tumor, all had preoperative skull base involvement and residual blood supply from the internal carotid artery following embolization. Sixty-seven percent (8/12) of patients with postoperative residual tumor demonstrated radiographic stability of disease with scans being completed approximately every 6 months. Radiographic rates of disease progression ranged from 4.1 to 9.22 mm/year. Conclusions Patients with preoperative skull base involvement and residual vascularity following preoperative embolization are more likely to have residual postoperative disease, and a longer postoperative follow-up is warranted in these patients. Progression of residual disease occurred approximately 7.5 months postoperatively. Younger patients may be more likely to need further intervention for postoperative residual disease, and postoperative imaging at 6-month intervals appears appropriate.

Objectives To identify the prevalence and risk factors for nasal deformities after endoscopic endonasal surgery (EES) of the skull base. Design Retrospective case series. Setting Tertiary referral academic center. Participants EES patients from January 2011 to October 2013. Main Outcome Measures Surgical approach, method of skull base reconstruction, and postoperative nasal deformities. Results Of 328 patients, 19 patients (5.8%) had nasal dorsum collapse, 3 (0.9%) with new septal perforations and 2 (0.6%) with septal deviations requiring surgical correction. Postoperative deformities were only found in the setting of nasoseptal flap reconstruction (p = 0.0001) and were most common in patients who had undergone an approach involving more than one anatomical subsite (p = 0.0021). Patients with nasal deformities were on average 6 years younger (p = 0.08) and were more likely to have a malignant pathology (p = 0.08). Conclusions All deformities were associated with use of a nasoseptal flap for reconstruction and were most common in combined approaches, suggesting that flap size may play a role in the development of nasal deformities. The mechanism of nasal dorsum collapse is unclear but does not appear to be related to septal cartilage necrosis. These findings warrant a prospective analysis to identify risk factors for postoperative nasal deformities and data for counseling of patients.

Objectives This study aimed to review endoscopic skull base surgeon experience with internal carotid artery (ICA) injuries during endoscopic endonasal surgery (EES) to provide an estimate of the incidence of ICA injury, the associated factors and identify the best training modalities for the management of this complication. Design Anonymous electronic survey of past participants at a well-established endoscopic skull base surgery course and a global online community of skull base surgeons. Main Outcome Measures Relative incidence of ICA injuries during EES, associated anatomic and intraoperative factors, and surgeon experience. Results At least 20% of surgeons in each surveyed population experienced a carotid artery injury. Reported carotid artery injuries were most common during tumor exposure and removal (48%). The parasellar carotid artery was the most commonly injured segment (39%). Carotid artery injuries were more common in high-volume surgeons, but only statistically significant in one of the two populations. Attendance at a skull base course or courses did not change the incidence of carotid artery injury in either surveyed population. In both surveys, respondents preferred live surgeries or active (not computer simulated) training models. Conclusions ICA injury is underreported and most common when manipulating the parasellar carotid artery for exposure and tumor dissection. Given the high morbidity and mortality associated with these injuries, vascular injury management should be prioritized and taught in a graduated approach by modern endoscopic skull base courses.