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Background: The ability to reliably and accurately cannulate the natural ostium of the maxillary sinus during balloon sinus dilation (BSD) has been criticized. Conventional computed tomography (CT)-guided navigation systems are helpful when dilating other sinuses, but they fail to provide meaningful feedback to guide accurate dilation of the maxillary sinus., Objective: This study explores the potential impact of a new navigation system with virtual reality (VR) functionality on successful BSD of the maxillary sinus., Methods: Using the established methodology, a cadaveric evaluation of the accuracy of maxillary BSD with a VR-equipped navigation system and balloon was undertaken. The natural ostium was landmarked on CT images with a beacon, and a VR intrasinus camera view was used to guide balloon dilation by a team of 2 rhinologists. Following the procedure, uncinectomies were performed to directly assess the accuracy of dilation. Standardized video clips with a 30° endoscopic view of the area were reviewed by 3 blinded rhinologists from different institutions who were not part of the procedures. Dilation of the natural ostium was scored as "successful," "unsuccessful," or "unsure.", Results: Sixteen maxillary BSDs were completed in 8 cadavers using VR navigation. The medial wall of the maxillary sinus showing the natural ostium as well as any accessory ostia were readily visualized and labeled with a beacon in all cases using the 3D virtual rendering feature. Dilations were scored using a standardized rubric. Any "unsure" responses from the reviewers were categorized as "unsuccessful" for analysis purposes. The accuracy rate for dilation of the maxillary sinus natural ostium was 77%. Despite the use of cadaveric tissues, a fair interrater agreement (kappa 0.21) was achieved., Conclusion: Using VR navigation appears to improve the accuracy of cannulating the natural ostium during maxillary BSD, which could lead to better outcomes. Further study in live subjects is warranted.

Background : Endoscopic sinus surgery presents significant visuospatial challenges to surgical trainees. We tested the utility of novel 3D printed models to simulate sinus surgery tasks to improve endoscopic skillsets in resident trainees. Methods : This was a prospective quality improvement study of 10 ENT residents (PGY1-5). Participants rotated through 4 stations with different 3D simulation training modules designed to enhance endoscopic skillsets in the axial, sagittal and coronal planes (e.g., straight forceps to grasp a bead from a ledge, angled instruments to cannulate openings). Participants completed a self-assessment survey on the subjective sinus surgical skills using a visual analog scale before and after tasks. Two- tailed paired T-tests were used to analyze the data. Results : All residents rated their post-intervention "overall sinus surgery skills" higher than pre-intervention. They rated simulations to provide more significant utility as an adjunct to surgical education after the intervention. All but one participant reported improved spatial awareness working with the endoscopes and surgical instruments. There was subjectively improved proficiency in using 0-degree and angled endoscopes as well as cutting, grasping, and curved instruments after the intervention. The simulations led to subjective improvements in spatial awareness, bimanual dexterity, and increased confidence in selecting correct surgical instruments. Conclusion : Our set of novel 3D printed models to improve sinus surgery skillset was well accepted by the resident cohort. The 3D models can serve as an adjunct tool to traditional residency education., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: WCY serves as a consultant for Aerin Medical and on the speaker’s bureau for Optinose Inc. AUL serves as a consultant for Lyra Therapeutics (Watertown, MA, USA), Medtronic (Dublin, IE), (Sanofi (Paris, France), and Stryker (Kalamazoo, MI, USA). AUL serves on the scientific advisory board for ENTvantage Dx (Austin, TX, USA) and Third Wave Therapeutics (San Francisco, CA, USA). AUL has served on advisory boards for AstraZeneca (Cambridge, UK) and Glaxo-SmithKline (Brentford, UK).

Introduction: Image-guided surgery (IGS) has gained widespread acceptance in otorhinolaryngology for its applications in sinus and skull base surgery. Although the core concepts of IGS have not changed, advances in image guidance technology, including the incorporation of intraoperative imaging, have the potential to enhance surgical education, allow for more rigorous preoperative planning, and aid in more complete surgery with improved outcomes., Objectives: Provide a clinical update regarding the use of image guidance and intraoperative imaging in the field of rhinology and endoscopic skull base surgery with a focus on current state of the art technologies., Methods: English-language studies published in PubMed, Cochrane, and Embase were searched for articles relating to image-guided sinus surgery, skull base surgery, and intraoperative imaging. Relevant studies were reviewed and critical appraisals were included in this clinical update, highlighting current state of the art advances., Conclusions: As image guidance and intraoperative imaging systems have advanced, their applications in sinus and skull base surgery have expanded. Both technologies offer invaluable real-time feedback on the status and progress of surgery, and thus may help to improve the completeness of surgery and overall outcomes. Recent advances such as augmented and virtual reality offer a window into the future of IGS. Future advancements should aim to enhance the surgeon's operative experience by improving user satisfaction and ultimately lead to better surgical results.

Background The use of abdominal free fat is a traditional surgical method for the repair and reconstruction of the anterior skull base. Our objective is to assess the outcomes associated with the autologous fat graft to endoscopically repair anterior skull base defects at a single tertiary care center. Methods All patients, who underwent endoscopic skull base repair utilizing abdominal free fat from September 2009 to June 2016, were included for retrospective chart review. Evaluated outcome measurements included (1) the successful closure of preoperative and intraoperative cerebrospinal fluid (CSF) leaks and (2) complications at both donor and recipient graft sites during the postoperative periods. Four representative clinical cases have additionally been selected to highlight the common indications for which the fat graft may be effective in skull base reconstruction. Results Of the 27 patients who were identified for inclusion in this review, 25 (92.6%) demonstrated successful repair of preoperative or intraoperative CSF leaks following primary skull base repair. Two patients developed recurrent CSF leaks occurring about 1 week after their primary closures, and a secondary closure rate of 96.3% was achieved with use of fat grafts. Other complications included seroma and hematoma formation at the abdominal donor sites, each occurring in 1 patient. Conclusions The use of autologous fat remains a viable option for grafting material during endoscopic skull base reconstruction. Despite the wide variety of closure techniques in skull base surgery, autologous fat provides safe and easily accessible material to repair CSF leaks.

Background: Odontogenic cysts and tumors of the maxilla may be amendable to management by endonasal endoscopic techniques, which may reduce the morbidity associated with open procedures and avoid difficult reconstruction., Objective: To perform a systematic review that evaluates the feasibility and outcomes of endoscopic techniques in the management of different odontogenic cysts. A case series of our experience with these minimally invasive techniques was assembled for insight into the technical aspects of these procedures., Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses was used to identify English-language studies that reported the use of endoscopic techniques in the management of odontogenic cysts. Several medical literature data bases were searched for all occurrences in the title or abstract of the terms "odontogenic" and "endoscopic" between January 1, 1950, and October 1, 2016. Publications were evaluated for the technique used, histopathology, complications, recurrences, and the follow-up period. A case series of patients who presented to a tertiary rhinology clinic and who underwent treatment of odontogenic cysts by an endoscopic technique was included., Results: A systematic review identified 16 case reports or series that described the use of endoscopic techniques for the treatment of odontogenic cysts, including 45 total patients. Histopathologies encountered were radicular (n = 16) and dentigerous cysts (n = 10), and keratocystic odontogenic tumor (n = 12). There were no reported recurrences or major complications for a mean follow-up of 29 months. A case series of patients in our institution identified seven patients without recurrence for a mean follow-up of 10 months., Conclusion: Endonasal endoscopic treatment of various odontogenic cysts are described in the literature and are associated with effective treatment of these lesions for an average follow-up period of >2 years. These techniques have the potential to reduce morbidity associated with the resection of these lesions, although comparative studies would better define specific indications.

We sought to evaluate the efficacy of ropivacaine in post-tonsillectomy pain management in adults and evaluate the timing of intraoperative ropivacaine administration for this purpose. A prospective, double-blinded, randomized, controlled trial with a paired design was performed in 25 consecutive adults undergoing tonsillectomy. To date, no studies examining the efficacy of local anesthetics in post-tonsillectomy pain control have used a paired design to account for the variability in pain difference between individuals. Patients were prerandomized into those receiving tonsillar fossa injections before or after the tonsillectomy. All surgeries were performed by the senior author. The tonsil on 1 side was injected with saline and the tonsil on the other side with ropivacaine. Patient responses were obtained via written questionnaire. Three of 25 patients were excluded from the study. Sixteen of 22 patients had lateralization of pain to 1 side during recovery. No statistically significant difference in pain control was observed between ropivacaine and normal saline. Local anesthetic decreased pain in 7 of 22 patients, and increased pain was experienced on the side with local anesthetic in 9 of 22 patients. Six of 22 patients had no difference in pain from one side to the other. The time to equalization of pain based on laterality was 8.8 and 6.8 days, respectively, in the patients injected before or immediately after the tonsillectomy. Administration of the local anesthetic ropivacaine does not affect post-tonsillectomy pain. Moreover, timing of injection does not affect postoperative pain. We recommend against the use of intraoperative ropivacaine for pain control in patients undergoing tonsillectomy.

Background: The progression from a benign pigmented lesion on the skin to cutaneous melanoma is better understood, and it could be presumed that a similar progression occurs with mucosal lesions. However, to our knowledge, there has never been documentation of melanosis transforming into melanoma over time., Objective: To describe a transformation of a mucosal melanosis into melanoma., Methods: A 53-year-old man with diffuse melanosis of the nasal cavity underwent surgical resection., Results: Pathology revealed melanocytic hyperplasia without evidence of melanoma. The patient was serially examined, with excisions for new areas of melanosis. The pathology progressed to severely atypical melanocytic proliferation and melanoma in situ over a 4-year period., Conclusion: Nasal melanosis may be a precancerous lesion and may transform into melanoma. All melanosis should be biopsied with close endoscopic observation. Lesions with dysplasia or atypia should be excised due to potential transformation to melanoma., Competing Interests: The authors have no conflicts of interest to declare pertaining to this article