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Background: Ventral skull base (VSB) surgery has associated morbidity and mortality that is poorly defined. In this study we aim to identify factors associated with adverse events in VSB surgery., Methods: We queried the database of the American College of Surgeons National Surgical Quality Improvement Program for cases of VSB surgery during the period 2005-2014. Patients with complications, readmissions, reoperations, or mortality were compared to those without adverse events., Results: Nine hundred patients were included; 253 (28.1%) had complications, underwent reoperation, were readmitted, or died. These patients were older (42.6% vs 32.8, p = 0.032) and had higher rates of congestive heart failure (CHF) (3.2% vs 0.2%, p < 0.0001), disseminated cancer (8.3% vs 4.6%, p = 0.032), and preoperative sepsis (8.7% vs 2.2%, p < 0.0001). Other comorbidities included long-term steroid use (13.4% vs 9.0%, p = 0.046) and higher rates of preoperative transfusion (2.4% vs 0%, p < 0.0001). The most common complication was bleeding (13.7%). Preoperative systemic sepsis (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.0-6.6) and lower hematocrit (OR, 2.1; 95% CI, 1.4-3.4) were more likely to be associated with a complication. Those with disseminated cancer (OR, 12.0; 95% CI, 2.9-50.5) were more likely to experience 30-day mortality. Black patients had lower rates of reoperation (OR, 0.3; 95% CI, 0.1-0.8), whereas patients with CHF (OR, 12.6; 95% CI, 1.7-94.4) and hypertension (OR, 2.1; 95% CI, 1.1-4.0) had higher rates of reoperation. Predictors of extended length of stay were Hispanic ethnicity (OR, 2.2; 95% CI, 1.2-4.1) and lower hematocrit (OR, 2.3; 95% CI, 1.5-3.6)., Conclusion: VSB surgery can involve significant morbidity and mortality, and thus identifying risk factors allows for better prognostication and delivery of care in these patients., (© 2019 ARS-AAOA, LLC.)

Background: Pediatric sinonasal rhabdomyosarcoma (RMS) is an aggressive and rare malignancy. This is the first multi-institutional study on the prognostic factors associated with outcomes in this population., Methods: The National Cancer Database was queried for the period from 2004 to 2013 for all cases of malignant sinonasal RMS in the pediatric population. The impact of patients' demographics, tumor characteristics, and Intergroup Rhabdomyosarcoma Study Group (IRSG) staging on survival was assessed using chi-square test, Fisher's exact test, Kaplan-Meier test, and Cox regression analyses., Results: A total of 157 cases of pediatric sinonasal RMS were identified. Mean age at diagnosis was 9.38 years and male patients comprised 48.4% of the cohort. The nasal cavity (31.8%) and maxillary sinus (30.6%) were the most common primary sites. Alveolar was the most common histology (49.7%), followed by embryonal type (32.5%). The majority of patients received solely chemoradiation (52.9%), followed by surgery with adjuvant chemoradiation (30.6%). Five-year overall survival (OS) was 55.2% (±4.5%). Metastatic disease was associated with a poorer 5-year OS rate (24.4% vs 61.5%; p = 0.010). Maxillary sinus site was associated with an improved survival (71.8% vs 47.6%; p = 0.009). On multivariate analysis, chemoradiation with or without surgery was an additional prognostic factor. Although IRSG clinical stages did not correlate with survival, high-risk patients in the IRSG clinical risk groups were associated with poorer survival on multivariate analysis (hazard ratio [HR], 2.005; 95% confidence interval, 1.007-3.993; p = 0.048)., Conclusion: To date, this is the largest study on pediatric sinonasal RMS. IRSG clinical risk groups may be useful in stratifying high-risk patients with poor prognosis., (© 2019 ARS-AAOA, LLC.)

Background: Elderly patients with multiple comorbidities may be at higher risk of postoperative complications. With an increasingly aging population, more data assessing for predisposing factors are needed in this at-risk group. In this study, we analyzed the effect of elderly status on relative comorbidities and complications of sinonasal cancer (SNC) patients receiving surgery., Methods: A retrospective database analysis was performed using cases from the Nationwide Inpatient Sample (NIS) from 2003 to 2012. Patients with a diagnosis of malignant neoplasm of the nasal cavity or paranasal sinuses, who received surgery for sinonasal malignancy, including neck dissections, were selected. Demographics of interest included age, sex, race, type of admission, mean length of stay, and median hospital charges. Elderly and nonelderly patients were compared for differences in rates of acute medical complications, acute surgical complications, and relevant procedures during hospitalization., Results: Of the 920 cases identified in the NIS, 382 (41.5%) were elderly (≥65 years). Cases of SNC were more frequently seen in males than females (p < 0.001). Elderly patients had significantly higher comorbidity rates compared with nonelderly patients, which included congestive heart failure, hypertension, diabetes, chronic pulmonary disease, and chronic renal failure (p < 0.001 for all). Elderly patients more frequently had postoperative cardiac complications (6.0% vs 0.5%, p < 0.001), but this finding was not statistically significant on multivariate analysis when controlling for race, sex, and comorbidities., Conclusion: Elderly status is not an independent factor for postoperative complications in patients undergoing surgery for sinonasal malignancy., (© 2018 ARS-AAOA, LLC.)

Background: Our aim in this study was to assess the impact of the turnover of residents in July on patients undergoing pituitary surgery., Methods: This work was a retrospective cohort study of cases from the National Inpatient Sample (NIS). Patients who underwent pituitary surgery from 2005 to 2012 were selected in the NIS. Patients undergoing surgery in July and in non-July months were compared to determine differences in demographics, comorbidities, and complications., Results: Of the 12,939 patients, 1098 (8.5%) underwent pituitary surgery in July. Patients receiving surgery in July had similar demographics and Agency for Healthcare Research and Quality comorbidity values compared with patients receiving surgery in other months. There were no significant differences in mortality, cerebral edema, cerebrospinal fluid leakage, iatrogenic pituitary complications, iatrogenic cerebrovascular accidents, urinary tract infections, pulmonary edema, pulmonary complications, or acute cardiac complications. There were no differences in the rate of postoperative fistulas, hematomas, perforations, or infections. The use of meningeal suturing, pedicled or free-flap reconstruction, and skin reconstruction was more frequent in July. Finally, hospitalization costs in July were similar to costs in other months., Conclusion: The turnover of new residents in July showed no change in complication rates for patients undergoing pituitary surgery. Patient care in July is similar to care during other months, demonstrating that hospitals are adequately supervising surgical residents during this transition., (© 2018 ARS-AAOA, LLC.)

Background: The use of endoscopic resection as an alternative to open surgery for sinonasal malignancies has increased in the past 20 years., Methods: The National Cancer Database was queried for cases of sinonasal squamous cell carcinoma (SNSCC) without cervical or distant metastases that were treated surgically between 2010 and 2014. They were split into 2 groups based on surgical approach: open or endoscopic. Demographics, facility and insurance type, stage, tumor characteristics, postoperative treatment, 30-day readmission rate, 30- and 90-day mortality, and overall survival (OS) were compared between the 2 groups. Cox proportional hazard analysis was performed. Propensity score matching (PSM) was used to mimic a randomized, controlled trial., Results: A total of 1,483 patients were identified: 353 (23.8%) received endoscopic and 1130 (76.2%) received open surgery. Age, gender, race, geographic region, tumor size, surgical margins, postoperative chemoradiation, and 30-day readmissions did not vary significantly between the 2 groups. Open surgery was more common in academic centers (62.8% vs 54.2%; p = 0.004), less common for tumors of the ethmoid and sphenoid sinus (p < 0.0001), less common for stage IVB tumors, and associated with longer hospital stay (mean, 4.67 days vs 2.50 days; p < 0.0001). Five-year OS (5Y-OS) was not significantly different between the 2 approaches (p = 0.953; open: 5Y-OS, 56.5%; 95% confidence interval, 51.3% to 61.6%; endoscopic: 5Y-OS, 46.0%; 95% confidence interval, 33.2% to 58.8%). In the PSM cohort of 652 patients, there was also no significant difference in OS (p = 0.850)., Conclusion: Endoscopic surgery is an effective alternative to open surgery, even after accounting for confounding factors that may favor its use over the open approach. It is also associated with a shorter hospital stay., (© 2017 ARS-AAOA, LLC.)

Background: Squamous cell carcinoma (SCC) is the most common malignancy in the sinonasal tract. We present the first population-based analysis that examines geographic differences in demographic and clinical characteristics, socioeconomic factors, treatment modality, and disease-specific survival (DSS) of this entity., Methods: All cases of sinonasal squamous cell carcinoma (SNSCC) were queried using the U.S. Surveillance, Epidemiology, and End Results (SEER) registry from 1973 to 2013. Patients were stratified by geographic location and characteristics such as demographics (age, gender, race, metropolitan/nonmetropolitan status, and income), stage at diagnosis, and treatment modality. Survival data were generated using Kaplan-Meier regression analysis., Results: In total, 6094 patients were identified; 15.3% were from the East, 16.3% from the Midwest, 19.3% from the South, and 49.1% from the West. Patients from the South were younger (p < 0.001). The South had the highest proportion of patients who were black (p < 0.001), lived in nonmetropolitan areas (p < 0.001), and presented with localized disease (p < 0.001). Southern patients also had the lowest median income (p < 0.05), and were least likely to be treated with both surgery and radiotherapy (p < 0.001). The South exhibited the lowest 20-year DSS compared to all other regions (p < 0.001)., Conclusion: SNSCC patients from the South had the poorest long-term DSS, despite being most likely to present with localized disease. The South had the highest proportion of patients who were black, resided in rural or urban towns, had the lowest median income, and did not receive standard combination therapy, compared to the East, Midwest, and West., (© 2017 ARS-AAOA, LLC.)

Background: The role of human papillomavirus (HPV) in sinonasal squamous cell carcinoma (SNSCC) is not well understood., Methods: The National Cancer Database was queried for cases of SNSCC with known HPV status. Demographics, socioeconomic variables, TNM stage, histology, grade, treatment modalities, and overall survival (OS) through 5 years were compared between HPV-positive and HPV-negative tumors. Cox proportional hazard regression analyses were performed., Results: Seven hundred seventy (770) cases were identified; 526 were HPV-negative (68.3%) and 244 (31.7%) were HPV-positive. Patients with HPV-positive tumors were younger (58.0 vs 63.7 years, p < 0.0001). Nasal cavity (49.4%) tumors were more likely to be HPV-positive (p < 0.05) than maxillary (18.8%), ethmoid (18.8%), and frontal (18.2%) sinus tumors. Large cell nonkeratinizing (42.4%), papillary (42.1%), and basaloid (56.5%) tumors were more likely than keratinizing (25.2%) tumors to be HPV-positive (p < 0.05). Well-differentiated (grade I) tumors (9.0%) were less likely than higher grade tumors to be HPV-positive (p < 0.05). Gender, race, facility type, insurance type, median income, education level, Charlson-Deyo comorbidity score, overall stage, T stage, N stage, M stage, tumor size, treatment modality, surgical approach, and surgical margins did not vary by HPV status (p ≥ 0.05). HPV-positive tumors had higher OS than HPV-negative tumors (p < 0.0001). At 5 years, OS was 68.1% and 51.5% for HPV-positive and HPV-negative tumors, respectively. On multivariate analyses, HPV positivity remained a favorable prognostic factor (hazard ratio, 0.49; 95% confidence interval, 0.34-0.70)., Conclusion: HPV positivity is more common in nasal cavity SCC and nonkeratinizing SNSCC. It is also a favorable prognostic factor in SNSCC. Future studies on SNSCC should take HPV positivity into consideration., (© 2017 ARS-AAOA, LLC.)

Background: Industry outreach promotes awareness of novel technologies. However, concerns have been raised that such relationships may also unduly impact medical decision-making. Our objective in this study was to evaluate industry relationships among practitioners who frequently employ balloon dilation (BD), characterizing whether there is any association between financial relationships and BD utilization., Methods: Provider utilization data (FY-2014) was accessed for individuals billing BD procedures to Medicare, the largest healthcare payor in the United States. The names of individuals included in these data sets were cross-referenced with the Centers for Medicare and Medicaid Services Open Payment site to determine the extent of industry relationships during this same year. Individuals included in this analysis were organized by those with "significant" ($1,000 to $10,000) and "major" (> $10,000) industry relationships. Practice setting, training, and experience were also evaluated., Results: Of the 302 otolaryngologists who billed enough BDs for inclusion in this data set, 99.3% were in private practice, 89.7% were board-certified, 8.3% had facial plastic and reconstructive fellowship training, and 1.3% had rhinology fellowship training. There was a significant increase in BDs performed with increasing BD company financial contributions (analysis of variance, p = 0.0003). Individuals without "significant" relationships with BD companies billed fewer BDs than those with at least "significant" (>$1,000) relationships (57.0 ± 4.3 vs 87.7 ± 10.0, p = 0.001)., Conclusion: There is an association between receiving money from industry and the frequency with which otolaryngologists employ BD. Although our analysis demonstrates an association, these results in no way imply causation. Further analysis exploring the reasons for this association may be necessary., (© 2017 ARS-AAOA, LLC.)

Background: Endoscopic sinus surgery (ESS) has become the treatment of choice for a variety of nasal conditions. The purpose of this study was to analyze the effect of diabetes mellitus (DM) on postoperative outcomes in ESS., Methods: Data on endoscopic sinus surgery performed from 2005 to 2013 were collected from the American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) database. Two groups were created, based on the presence of a DM diagnosis, and were analyzed for preoperative variables, comorbidities, and postoperative complications using SPSS statistical software., Results: There were 644 patients included in the analysis, 85 of whom (13.2%) had a diagnosis of DM. Patients with DM were more likely to have higher rates of preoperative dyspnea and hypertension. After accounting for confounding factors, DM patients undergoing ESS were at higher risk of overall medical complications, pneumonia, unplanned reintubation, ventilator use of >48 hours, and mortality. However, after separating patients into outpatient and inpatient groups, DM was found to be an independent predictor of urinary tract infection in outpatients and of ventilator use >48 hours in inpatients., Conclusion: DM patients undergoing ESS are at increased risk for postoperative medical complications. However, DM does not appear to increase the postoperative surgical complication rate in this population. Furthermore, DM does not appear to have an impact on ESS mortality, readmission, or reoperation rates., (© 2017 ARS-AAOA, LLC.)

Background: Currently, limited literature exists about sinonasal adenoid cystic carcinoma (SNACC). In this study, we analyze the demographics, survival, and treatment efficacy of this rare entity., Methods: Our study was a retrospective population-based analysis of SNACC in the Surveillance, Epidemiology, and End Results (SEER) database assessing the 40-year time-frame of 1973 to 2013., Results: Six hundred ninety-four SNACC patients were identified; 53.2% were female and 46.8% were male. Caucasians were most commonly affected (77.1%). SNACC most often arose from the maxillary sinuses, followed by the nasal cavity. The majority of SNACC cases presented as stage IV disease. Nodal and distant metastases were present in 3.6% and 7.1% of all cases, respectively. Overall 5-, 10-, and 20-year disease-specific survival (DSS) rates were 66.5%, 41.1%, and 17.6%, respectively. The presence of distant metastasis dropped the 5-year DSS rate from 64.5% to 20.0%. Cases treated with combined surgery and adjuvant radiotherapy had a slightly improved 5-year DSS rate compared with surgery alone (73.5% vs 72.5%). Surgery alone resulted in higher 10- and 20-year DSS rates (54.2% and 36.8%, respectively) when compared with combined therapy (44.2% and 15.5%), radiotherapy alone (10.8% and 0%), and no surgery or radiotherapy (9.3% and 0%)., Conclusion: This study represents the largest cohort of SNACC patients to date. Factors that confer a survival benefit in SNACC include M0 disease, and presentation primarily in the nasal cavity. Overall low rates of nodal metastasis may not warrant the use of elective neck dissections, unless there is clinical suspicion. Modalities of therapy that include surgery greatly improve survival. Adjuvant radiotherapy appears to slightly improve 5-year disease-free survival but does not impact long-term survival., (© 2016 ARS-AAOA, LLC.)

Background: Sinonasal malignancies are rare, representing less than 1% of all cancers, with the sphenoid sinus accounting for 1% to 2% of these cases. Sphenoid sinus malignancies exhibit very poor outcomes. There is a paucity of literature describing their histopathological features, incidence trends, treatment, and survival. We seek to elucidate these factors using a national population-based resource., Methods: The Surveillance, Epidemiology, and End Results (SEER) database was used to identify malignant sphenoid sinus tumors. The results were analyzed for demographics, incidence, and clinicopathologic trends. Survival was calculated using Kaplan-Meier analysis., Results: The search identified 472 cases. The mean and median age at diagnosis was 60.0 years. Males represented 54.9% of cases. By race/ethnicity, 82.4% were white and 8.5% were black. The four most common histopathologies were squamous cell neoplasms (29.4%), adenocarcinomas (14.4%), non-Hodgkin's mature B-cell lymphomas (13.1%), and unspecified epithelial neoplasms (11.0%). The overall incidence from 2000 to 2012 was 0.030 per 100,000. Kaplan-Meier analysis demonstrated an overall 5-year disease-specific survival (DSS) of 48.1%. Of the most common histopathological subtypes, 5-year DSS was best for mature B-cell NHL (64.0%) and worst for unspecified epithelial neoplasms (25.6%)., Conclusion: Sphenoid sinus malignancies are rare, with high prevalence in white males. The most common histopathology is squamous cell neoplasms. They exhibit significant locoregional extension. Of the common sphenoid sinus malignant subtypes, 5-year DSS is best for mature B-cell NHL and worst for unspecified epithelial neoplasms., (© 2016 ARS-AAOA, LLC.)

Background: Primary fibrosarcoma of the sinonasal region is an infrequently occurring malignant neoplasm. Fibrosarcomas are most commonly found in the extremities, with only 1% of fibrosarcomas reported in the head and neck region. This study analyzes the demographic, clinicopathologic, and survival characteristics of sinonasal fibrosarcoma (SNFS)., Methods: The Surveillance, Epidemiology, and End Results (SEER) database (1973 to 2012) was queried for SNFS cases. Data were analyzed with respect to various demographic and clinicopathologic factors. Survival was analyzed using the Kaplan-Meier model., Results: Fifty-one cases of fibrosarcoma were identified in the sinonasal region. The mean age at diagnosis was 54.5 years and the mean survival was 119.7 months. There was no gender predilection with a male-to-female ratio of 1.04:1. The maxillary sinus was the most common site of involvement (54.9%), followed by the nasal cavity (23.5%). Five-year survival analysis revealed an overall survival rate of 71.7%, disease-specific survival rate of 77.8%, and relative survival (RS) rate of 78.8%. Disease-specific survival was better among those treated with surgery (with [76.2%] or without [87.5%] adjuvant radiotherapy) than those treated with primary radiotherapy alone (33.3%) (p = 0.0069)., Conclusion: SNFS is a rare entity. This study represents the largest series of SNFS to date. The mainstay of treatment for this tumor is surgical resection with or without radiotherapy., (© 2015 ARS-AAOA, LLC.)

Background: Sinonasal extramedullary plasmacytoma (SN-EMP) is a rare plasma cell neoplasm. Published literature on this tumor largely consists of case reports and case-series with small sample sizes. This study analyzed population-based data on SN-EMP patients to understand demographic and clinical features as well as incidence and survival trends., Methods: The Surveillance, Epidemiology, and End Results (SEER) database was queried for SN-EMP and other head and neck EMP (HN-EMP) cases from 1973 to 2011. Cases were analyzed to determine patient demographics, initial treatment modality, and survival outcomes., Results: Of 778 patients identified with EMP in the head and neck region, 367 patients had SN-EMP and 411 had other HN-EMP. There was a strong male predilection found, with a male-to-female ratio of 3.65:1 in the SN-EMP group and 1.87:1 in the other HN-EMP group. The majority of the patients presented with localized disease in both SN-EMP (84.4%) and other HN-EMP (81.0%) groups. The most common treatment modality reported in this database was surgery with adjuvant radiotherapy in both SN-EMP (46.3%) and other HN-EMP (38.9%) groups, followed by radiotherapy alone (SN-EMP: 40.7%; other HN-EMP: 34.2%). Five-year and 10-year disease-specific survival rates were comparable between SN-EMP (88.2% and 83.3%, respectively) and other HN-EMP (90.0% and 87.4%, respectively) (p = 0.6016 and p = 0.4015, respectively)., Conclusion: This study analyzed the largest cohort of SN-EMP patients to date. There was no statistically significant survival advantage found for any 1 particular treatment modality over other treatment modalities in both SN-EMP and other HN-EMP., (© 2015 ARS-AAOA, LLC.)

Background: Endoscopic endonasal surgery (EES) is a relatively novel approach to the craniovertebral junction (CVJ). The purpose of this analysis is to determine the surgical outcomes of patients who undergo purely EES of the CVJ., Methods: A search for articles related to EES of the CVJ was performed using the MEDLINE/PubMed database. A bibliographic search was done for additional articles. Demographics, presenting symptoms, imaging findings, complications, follow-up, and patient outcomes were analyzed., Results: Eighty-five patients from 30 articles were included. The mean patient age was 47.9 ± 24.8 years (range, 3 to 96 years), with 44.7% being male. The most common presenting symptom was myelopathy (n = 64, 75.3%). The most common indications for surgery were brainstem compression secondary to basilar invagination (n = 41, 48.2%) and odontoid pannus (n = 20, 23.5%). Odontoidectomy was performed in 97.6% of cases. Intraoperative complications occurred in 16 patients (18.8%) and postoperative complications occurred in 18 patients (21.2%). Six patients developed postoperative respiratory failure necessitating a tracheostomy. Neurologic improvement was seen in 89.4% of patients at a mean follow-up of 22.2 months., Conclusion: Our analysis found that EES of the CVJ results in a high rate of neurologic improvement with acceptable complication rates. Given its minimally invasive nature and high success rate, this approach appears to be a reasonable alternative to the traditional transoral approach in select cases. This study represents the largest pooled sample size of EES of the CVJ to date. Increasing use of the endoscopic endonasal approach will allow for further studies with greater statistical power., (© 2015 ARS-AAOA, LLC.)

Background: Fewer than 4% of pituitary tumors are malignant lesions. These tumors predominantly represent metastatic disease from elsewhere. This study evaluates inpatient complications, demographics, and hospitalization characteristics of patients who underwent transsphenoidal surgery (TSS) for malignant pituitary lesions., Methods: The Nationwide Inpatient Sample was evaluated for TSS patients from 1998 to 2010. Demographics, hospitalization characteristics, and complications were evaluated among patients with malignant lesions and compared to those with benign tumors., Results: There were 17,425 inpatient records, 1.0% of which involved malignant pituitary tumors. There was no difference in age between these cohorts (p = 0.378). Patients with malignant tumors had greater length of stay (6.7 days vs 4.5 days, p = 0.003) and higher trending charges ($55,371 vs $40,550 p = 0.091). The most common postoperative complications among patients with malignant lesions included diabetes insipidus (DI) (17.9%), fluid/electrolyte abnormalities (14.0%), neurological complications (5.6%), cerebrospinal fluid (CSF) rhinorrhea (2.2%), and iatrogenic pituitary disorders (2.2%). Patients with malignant lesions had a significantly greater rates of postoperative DI and fluid/electrolyte abnormalities (odds ratio = 2.0 and 1.7, respectively), whereas no statistical difference was noted in the rates of CSF rhinorrhea (p = 0.372)., Conclusion: In this analysis of inpatient hospitalizations for TSS patients, malignant pituitary disease was associated with a greater rate of postoperative DI and fluid/electrolyte abnormalities, but no differences in the rates of postoperative CSF rhinorrhea and other complications were found. Patients with malignant pituitary lesions undergoing TSS had significantly longer hospitalizations and higher trending charges than those with benign lesions. This analysis is, however, subject to the limitations of the database., (© 2015 ARS-AAOA, LLC.)

Background: Transsphenoidal surgery (TSS) is a common procedure for a variety of pituitary lesions. This procedure can be associated with complications related to the surgery or specific pathology. In this study, we evaluate inpatient postoperative complications among patients who underwent TSS for growth hormone adenomas using a nationally representative database, and compare patient characteristics and complications to patients who underwent TSS for other benign pituitary neoplasms., Methods: Analysis of the Nationwide Inpatient Sample revealed 13,070 TSS patients (including 892 with acromegaly) between 2002 and 2010. Complication rates, outcomes, patient demographics, hospital stay, and total charges were evaluated among TSS patients with and without acromegaly., Results: There was an increase in TSS performed in both cohorts from 2002 to 2010. Acromegaly patients were younger, had shorter hospital stays, and incurred fewer charges. Acromegaly patients had a lower occurrence of postoperative urinary/renal complications (0.2% vs 1.1%), thromboembolic events (0% vs 0.4%), fluid/electrolyte abnormalities (5.7% vs 9.1%), and iatrogenic hypopituitarism (0.3% vs 1.1%) compared to other TSS patients (all p < 0.05). After adjusting for age, acromegalic patients maintained a statistically lower occurrence of fluid/electrolyte abnormalities (p = 0.007). Cerebrospinal fluid leak occurrence in acromegaly patients was 2.6% vs 1.7% in non-acromegaly patients, a result that did not reach significance (p = 0.054)., Conclusion: Upon comparison of inpatient hospitalizations for patients undergoing TSS for growth hormone adenomas and other benign pituitary neoplasms, acromegaly patients had a significantly lower occurrence of postoperative fluid/electrolyte abnormalities. Acromegaly patients had shorter hospitalizations and subsequently fewer total charges., (© 2015 ARS-AAOA, LLC.)

Background: Sinonasal neuroendocrine carcinoma (SNEC) is a rare, aggressive tumor usually associated with a poor prognosis. This study analyzes the clinicopathological characteristics and survival outcomes of SNEC using population-based data., Methods: The Surveillance, Epidemiology, and End Results (SEER) database (1973 to 2011) was queried for SNEC cases. Data analyzed included patient demographics, incidence, treatment modality, and survival., Results: A total of 201 cases of SNEC were identified. Mean age at diagnosis was 55.8 ± 15.7 years. Overall 5-year disease-specific survival (DSS) rate for SNEC was 50.8%. Five-year survival analysis for SNEC by site revealed DSS of 80.7%, 59.2%, 34.5%, and 33.0% for the sphenoid sinus, nasal cavity, maxillary sinus, and ethmoid sinus, respectively (p = 0.0014). Cox proportional hazard analysis revealed greater hazard of death for the maxillary (hazard ratio [HR] 2.14; 95% confidence interval [CI], 1.21 to 3.71; p = 0.0094) and ethmoid sinuses (HR 1.83; 95% CI, 1.05 to 3.16; p = 0.0345) when compared to the nasal cavity. Advanced stage disease (stages III to IV, 5-year DSS 40.5%, p = 0.0008) was associated with poor survival outcomes. Survival was better among those treated with surgery (with [59.4%] or without [69.0%] radiotherapy) than those treated with primary radiotherapy alone (39.9%) (p < 0.0001)., Conclusion: SNEC commonly presents at an advanced-stage with poor survival outcomes. Negative prognostic factors include primary tumor site and advanced stage disease. SNEC is a highly aggressive tumor necessitating surgery and/or surgery with adjuvant radiotherapy as the treatment of choice., (© 2015 ARS-AAOA, LLC.)

Background: Variants of squamous cell carcinoma (SCC) make up 15% of all cases of SCC of the upper aerodigestive tract. There are 5 main histologic variants of SCC in the head and neck region: verrucous (VSCC), papillary (PSCC), spindle cell (sarcomatoid) (SCSC), basaloid (BSCC), and adenosquamous (ASC). Conventional sinonasal SCC has been studied extensively, but far less is known about its major variants., Methods: The Surveillance, Epidemiology, and End Results (SEER) database was used to extract frequency and survival data from 1973 to 2009. A total of 4382 cases of conventional sinonasal SCC and 328 cases of its major variants were found. Statistical comparisons of data for sinonasal SCC and its variants were carried out with respect to varying demographic and disease specific parameters, such as gender, race, age at diagnosis, and specific anatomic site affected., Results: Sinonasal BSCC was diagnosed at a significantly lower mean age than sinonasal SCC. Sinonasal SCSC significantly affected the maxillary sinus more commonly than SCC. In the setting of advanced stage disease, sinonasal VSCC, PSCC, and BSCC appear to be associated with a better prognosis than conventional sinonasal SCC, whereas the impact of histologic subtype on prognosis in early stage disease appears to be more limited. Survival for SCSC and ASC, both regarded as more lethal variants, was statistically similar to conventional SCC., Conclusion: Our study supports the practice of distinguishing between conventional sinonasal SCC and its major histologic variants, because histologic subtype appears to carry important prognostic implications., (© 2014 ARS-AAOA, LLC.)

Background: Mucoepidermoid carcinoma (MEC) is the most common salivary gland (SG) malignancy. Primary sinonasal MEC (SN-MEC) is rare. This study analyzes the demographic, clinicopathologic, and survival characteristics of SN-MEC and establishes comparisons with primary major SG-MEC., Methods: The Surveillance, Epidemiology, and End Results (SEER) database (1973 to 2010) was queried for SN-MEC (149 cases) and SG-MEC (4234 cases). Data were analyzed comparatively with respect to various demographic and clinicopathologic factors. Survival was analyzed using the Kaplan-Meier and Cox proportional hazards models., Results: Mean ± standard deviation (SD) age at diagnosis for SN-MEC was 58.6 ± 16.6 years. High histologic grade (ie, grades III and IV) at the time of diagnosis was more common among SN-MEC than SG-MEC (42.3% vs 25.5%, p < 0.0001). Overall 5-year disease-specific survival (DSS) was 61.7% for SN-MEC and 84.1% for SG-MEC (p < 0.001). For SN-MEC, factors associated with poor prognosis were age (75+ years; hazard ratio [HR], 3.38; 95% confidence interval [CI], 1.25 to 9.51), higher tumor grade (grade III and IV; HR, 3.62; 95% CI, 1.75 to 8.22), larger tumor size (>4 cm; HR, 8.36, 95% CI, 1.59 to 153.74), and primary tumor site (ethmoid sinus; HR, 2.95; 95% CI, 1.28 to 6.23) (all p < 0.05). Survival was better among those treated with surgery (with [64.4% survival] or without [81.3% survival] adjuvant radiation therapy) than those treated with primary radiation therapy alone (25.6% survival) (p < 0.05)., Conclusion: This report represents the largest series of SN-MEC to date. Although SN-MEC and SG-MEC share a common histology, there are important clinical differences between the 2 conditions., (© 2014 ARS-AAOA, LLC.)

Background: The purpose of this work was to study the demographics and survival of patients diagnosed with sinonasal adenocarcinoma (SNAC) within the time period of 1973 to 2009 using the Surveillance, Epidemiology, and End Result (SEER) database., Methods: A retrospective cohort study using the U.S. National Cancer Institute's SEER registry was performed to study the demographics and survival for SNAC from 1973 to 2009. Analysis was conducted based on race, gender, and stage., Results: In total, 1270 cases of SNAC were analyzed for demographics and survival. Males accounted for 51.6% of cases, while females accounted for 48.4% of cases, amounting to a male to female ratio of 1.06:1.00. Disease specific survival at 5, 10, 15, and 20 years was 65.2%, 50.9%, 40.9%, and 36.5%, respectively. When analyzed by gender, females had higher survival than males, although this difference was not statistically significant. When analyzed by race, the category of other, which encompasses American Indian, Asian, Hispanic, and unknown or unspecified race, was shown to have the best survival, followed by whites and blacks, respectively., Conclusion: SNAC is a rare tumor classically associated with occupational exposure and carries a variable prognosis. This is the first dedicated large-scale, retrospective analysis of a North American SNAC population. SNAC appears to affect both males and females equally and predominantly affects whites. Patients categorized as other had significantly better survival outcomes, while gender appeared to have no significant effect on survival., (© 2014 ARS-AAOA, LLC.)

Background: Eosinophilic angiocentric fibrosis (EAF) is a benign rare lesion of the upper respiratory mucosa. EAF most commonly presents with an obstructive nasal mass. Due to the rarity of EAF, case reports and case studies have predominated the literature. This systematic review discusses the demographics, clinical presentation, associated findings, management, and outcomes of this uncommon entity., Methods: The PubMed database was searched for all articles describing patients diagnosed with sinonasal EAF. Additional cases were examined from the bibliographies of selected articles. Demographics, clinical presentation, associated findings, radiography, management, and outcome were analyzed., Results: Fifty-two cases were included from 34 articles, including 1 case from our institution. The most common presenting symptom was nasal obstruction (78.8%). Fourteen patients (26.9%) had a previous history of nasal surgery or trauma. Surgical resection alone was the most commonly used primary treatment approach (50.0%), resulting in the greatest proportion of disease-free patients (55.6%) over a median follow-up period of 36 months. A combination of surgery and corticosteroids was the second-most-common treatment modality, used in 28.8% of cases. Of the 40 cases reporting patient outcomes, 100% of patients were alive at follow-up independent of treatment modality., Conclusion: To date, this review contains the largest number of patients with sinonasal EAF. Aggressive surgical resection alone constitutes the most common treatment modality and may be most effective at eradicating disease., (© 2014 ARS-AAOA, LLC.)

Background: Nasopharyngeal squamous cell carcinoma (NPSCC) is uncommon in non-endemic regions. Two major histologic subtypes are recognized: keratinizing (K-NPSCC) and nonkeratinizing (NK-NPSCC). We hypothesize that significant differences exist between the 2 in terms of demographic, clinicopathologic, survival, and prognostic features. We aim to show that differentiating between the 2 subtypes is perhaps the most important first step at the time of diagnosis., Methods: Using a retrospective cohort design, the U.S. National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) registry was used to extract data on the 2 major subtypes of NPSCC. Frequency, incidence, and relative survival (RS) were analyzed comparatively. Regression analysis was conducted and hazard ratios (HRs) calculated., Results: A total of 1624 cases were identified: 1234 (76.0%) cases of NK-NPSCC and 390 (24.0%) cases of K-NPSCC. Five-year RS was 60.6% for NK-NPSCC and 40.5% for K-NPSCC. Regression analysis revealed K-NPSCC to be a poor prognostic factor (HR 2.1; 95% confidence interval, 1.8-2.6; p < 0.0001). Other factors associated with a poor prognosis included female gender in K-NPSCC, age greater than 44 years in both groups, and advanced-stage disease at diagnosis. Favorable prognostic factors included Asian/Pacific Islander race, and treatment with radiation therapy. Higher histologic grade did not portend a worse prognosis for either group., Conclusion: NPSCC remains an uncommon malignancy in the United States. K-NPSCC and NK-NPSCC represent 2 different histologic entities with important clinical differences. K-NPSCC carries a worse overall prognosis when compared to NK-NPSCC., (© 2014 ARS-AAOA, LLC.)

Background: This study reviews the published literature related to extramedullary sinonasal plasmacytomas. Clinical presentation, demographics, treatment, and outcomes of this uncommon disease are reported., Methods: A systematic review of studies for sinonasal plasmacytomas from 1950 to 2012 was conducted. A PubMed database search, both for articles related to this condition along with bibliographies of those selected articles, was performed. Articles were examined for patient data that reported disease outcome., Results: Sixty-seven journal articles were included in this analysis, comprising a total of 175 cases. Radiotherapy was the most common treatment modality, used in 89 cases, followed by a combination of surgery and radiotherapy, and surgery alone. A total of 71.8% of patients were alive after a median follow-up of 39 months, independent of treatment modality. A combination of radiotherapy and chemotherapy was rarely used but had the best treatment outcome, with 88.9% of patients (8/9 patients) alive. Of the 3 most common treatment modalities, a combination of radiotherapy and surgery had the most favorable outcomes. Sixteen patients (9.1%) converted to multiple myeloma, with the majority of these patients (75.0%) receiving radiotherapy alone as their treatment modality., Conclusion: This review contains the largest pool of sinonasal plasmacytoma patients to date and suggests aggressive radiotherapy is the most common treatment modality for this condition. Of the 3 most common treatment modalities, a combination of surgery and radiotherapy was shown to have the best survival outcomes., (© 2013 ARS-AAOA, LLC.)

Background: Sinonasal melanoma (SNM) is a rare malignancy that commonly presents at an advanced age and has a slight male predominance. Local recurrence has been implicated as a major reason for treatment failure, and there are poor reported 5-year survival rates. We analyzed the impact of specific location within the sinonasal region on the survival of this rare malignancy., Methods: The U.S. National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) registry was used to extract data on SNM between 1973 and 2009. Survival trends and hazard ratios (HRs) were calculated to compare the prognostic implications of involvement of varying areas of the sinonasal tract., Results: A total of 567 cases were identified. Females constituted 56.44% patient. Disease-specific survival (DSS) at 5 years was 36.66% for patients diagnosed with nasal cavity disease, 23.80% for patients with maxillary sinus tumors, and 18.20% for patients with ethmoid sinus disease. Patients showing evidence of overlapping sinus involvement had approximate 1-year survival of 54.45% and none survived beyond 49 months. HRs for maxillary sinus, ethmoid sinus, and overlapping sinus disease were 1.34, 1.60, and 2.30, respectively. All DSSs and HRs were statistically significant (p < 0.05). There was a higher proportion of earlier-stage disease in the nasal cavity compared to the most common paranasal sinus region (p < 0.05)., Conclusion: Prognosis in SNM is dependent on the anatomic subsite. Paranasal sinus involvement indicates a poorer prognosis when compared to nasal cavity disease. Patients presenting with overlapping sinus involvement have the poorest prognosis., (© 2013 ARS-AAOA, LLC.)

Background: Our objectives were to evaluate collaboration with medical students and other nondoctoral authors, and assess whether mentoring such students influences the academic productivity of senior authors., Methods: Six issues of the Laryngoscope and International Forum of Allergy & Rhinology (IFAR) were examined for the corresponding author of each manuscript, and whether any students were involved in authorship. The h-index of all corresponding authors was calculated using the Scopus database to compare the scholarly impact of authors collaborating with students and those collaborating exclusively with other physicians or doctoral-level researchers., Results: Of 261 Laryngoscope manuscripts, 71.6% had exclusively physician or doctoral-level authors, 9.2% had "students" (nondoctoral-level authors) as first authors, and another 19.2% involved "student" authors. Corresponding values for IFAR manuscripts were 57.1%, 6.3%, and 36.5%. Corresponding authors who collaborated with students had higher scholarly impact, as measured by the h-index, than those collaborating exclusively with physicians and doctoral-level scientists in both journals., Conclusion: Collaboration with individuals who do not have doctoral-level degrees, presumably medical students, has a strong association with scholarly impact among researchers publishing in the Laryngoscope and IFAR. Research mentorship of medical students interested in otolaryngology may allow a physician-scientist to evaluate the students' effectiveness and functioning in a team setting, a critical component of success in residency training, and may have beneficial effects on research productivity for the senior author., (© 2013 ARS-AAOA, LLC.)

Background: To determine whether American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) Centralized Otolaryngology Research Efforts (CORE) grants influence career paths and scholarly impact of fellowship-trained rhinologists, and whether funding from the National Institutes of Health (NIH) and CORE programs is associated with increased scholarly impact among rhinologists. Another aim was to explore whether obtaining CORE grant funding is associated with NIH award acquisition., Methods: Practice setting, academic rank, and fellowship-training status were determined for individuals in the CORE grant database. The h-index and publication experience of practitioners was calculated using the Scopus database. Faculty listings were used to determine this data for a non-CORE-grants-funded "control" group of academic rhinologists. Active and past NIH funding was obtained using the NIH RePORTER database., Results: Fifteen of 26 (57.7%) fellowship-trained rhinologists receiving CORE grants were funded for rhinologic projects. Five of 6 rhinologists receiving NIH funding had a CORE-grants-funding history. Twenty-two of 26 (84.6%) rhinologists receiving CORE funding are currently in academic practice. Academic rhinologists receiving CORE or NIH funding had higher h-indices, a result reaching significance among promoted faculty and those with greater than 10 years of publication experience., Conclusion: Encouraging the pursuit of CORE grants among junior faculty as well as trainees interested in rhinology may be a strategy for developing highly effective research habits that pay dividends after the first few years of one's career. Fellowship-trained rhinologists with a CORE funding history predominantly pursue careers in academic medicine, although their CORE projects are not necessarily related to rhinologic topics., (© 2013 ARS-AAOA, LLC.)

Background: The purpose of this study was to examine litigation involving epistaxis and analyze factors that determine liability., Methods: Jury verdicts and settlements regarding cases involving epistaxis were gathered utilizing the Westlaw database. Factors involved in litigation gathered included demographics, defendant specialty, procedure, alleged cause of malpractice, outcome, monetary award, and other variables., Results: A total of 26 cases were analyzed. The majority of cases (57.7%) were decided in favor of the plaintiff or settled out of court. Total awards amounted to $24,501,252. Average awards for cases decided in favor of the plaintiff were $2,260,893 and ranged from $499,845 to $9,022,643. Settlements averaged $1,084,375 and ranged from $300,000 to $3,800,000. Common causes of malpractice encountered included delay in diagnosis, complications from medical procedures, and failure to recognize complications in a timely manner., Conclusion: Contrary to previous reports analyzing malpractice for varying medical procedures and complications, litigation in epistaxis is more commonly resolved in favor of the plaintiff or resolved through out-of-court settlements. Substantial financial awards and therapeutic complications from blindness to death make epistaxis a candidate for litigation. Of importance from a medicolegal stand is the fact that 30.8% (8) of the patients involved in epistaxis litigation died, either from complications of therapy or from experiencing epistaxis as a complication of another procedure/pathology. Using necessary diagnostic imaging, ensuring proper management techniques, and recognizing complications in a timely manner can serve to limit legal liability and enhance patient safety., (© 2013 ARS-AAOA, LLC.)

Background: The use of image-guidance (IG) in endoscopic sinus surgery (ESS) has escalated over the last decade despite a lack of consensus that its use improves outcomes or decreases complications. One theoretical reason for using IG in ESS is its potential to minimize legal liability should an adverse outcome occur. In this study, we aimed to characterize the role of IG in ESS litigation, and further detail other factors in pertinent cases. A secondary objective was to characterize recent malpractice litigation for other relevant factors., Methods: Relevant cases from Westlaw were examined to determine whether the use of IG played a role in initiating litigation in ESS malpractice suits. Factors such as patient demographics and alleged cause(s) of malpractice litigation were examined., Results: Out of 30 malpractice cases from 2004 to April 2013, 4 (13.3%) mentioned the use of IG during ESS, although this did not appear to be a factor affecting the plaintiff's decision to initiate litigation, nor the case outcomes. In the 26 cases (86.7%) in which IG was not used, its non-use was not specified as an alleged cause of negligence. Eleven (36.7%) cases were resolved in the defendant's favor. Frequently-cited factors included iatrogenic injury (83.3%), permanent deficits (66.7%), needing additional surgery (63.3%), orbital and intracranial injury, and perceived deficits in informed consent (40.0%)., Conclusion: The use of IG was not found to be a factor in ESS litigation. This suggests that not using IG does not necessarily make one more vulnerable to malpractice litigation., (© 2013 ARS-AAOA, LLC.)

Background: The potentially severe complications resulting from cerebrospinal fluid (CSF) leak makes iatrogenic injury a medicolegal area of concern for otolaryngologists and neurosurgeons. The objectives of this analysis were to study legal outcomes as well as medical and nonmedical elements affecting malpractice litigation., Methods: Public court records available in the Westlaw legal database (Thomson Reuters, New York, NY) were searched for medical malpractice litigation related to iatrogenic CSF leak. Of the 18 jury verdicts and settlements included, outcomes and awards, patient demographic data, and other factors instrumental in determining legal responsibility were recorded for comparison., Results: Ten (55.6%) cases were resolved in the defendant's favor, 2 (11.1%) resulted in damages awarded by a jury, and 6 (33.3%) were settled out of court before resolution of trial. Mean damages awarded were $1.1 million, while out of court settlements averaged $966,887. Malpractice stemming from patients who underwent endoscopic sinus surgery comprised 77.8% of cases analyzed. The most frequent alleged factors cited for litigation included having to undergo additional surgery (88.9%), developing meningitis (50.0%), and failing to recognize complications in a timely manner (44.4%). Perceived deficits in informed consent were alleged in one-third of cases., Conclusion: Although a slight majority of cases were resolved in the defendant's favor, payments made were considerable, averaging approximately $1 million. Strategies to decrease liability and allow patients to make more informed decisions should include clear communication with patients that explicitly states potential risks, such as meningitis, and possible need to undergo additional reparative surgery., (© 2013 ARS-AAOA, LLC.)

Background: The extensive amount of medical literature available on the Internet is frequently accessed by patients. To effectively contribute to healthcare decision-making, these online resources should be worded at a level that is readable by any patient seeking information. The American Medical Association and National Institutes of Health recommend the readability of patient information material should be between a 4th to 6th grade level. In this study, we evaluate the readability of online patient education information available from the American Rhinologic Society (ARS) website using 9 different assessment tools that analyze the materials for reading ease and grade level of the target audience., Methods: Online patient education material from the ARS was downloaded in February 2012 and assessed for level of readability using the Flesch Reading Ease, Flesch-Kincaid Grade Level, Simple Measure of Gobbledygook (SMOG) Grading, Coleman-Liau Index, Gunning-Fog Index, FORCAST formula, Raygor Readability Estimate, the Fry Graph, and the New Dale-Chall Readability Formula. Each article was pasted as plain text into a Microsoft® Word® document and each subsection was analyzed using the software package Readability Studio Professional Edition Version 2012.1., Results: All healthcare education materials assessed were written between a 9th grade and graduate reading level and were considered "difficult" to read by the assessment scales., Conclusion: Online patient education materials on the ARS website are written above the recommended 6th grade level and may require revision to make them easily understood by a broader audience., (© 2013 ARS-AAOA, LLC.)