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Background: Central compartment atopic disease (CCAD) and eosinophilic chronic rhinosinusitis (eCRS) are two clinical phenotypes of primary diffuse type 2 chronic rhinosinusitis (CRS) defined in the European Position Paper on Rhinosinusitis 2020 classification. Currently, the distinction between these subtypes relies on phenotypic features alone. Objective: This study aimed to investigate whether eosinophil activation differed between CCAD and eCRS. Methods: A cross-sectional study was conducted of adult patients presenting with CCAD and eCRS who had undergone functional endoscopic sinus surgery. Routine pathology results were obtained from clinical records. Eosinophils were counted on haematoxylin and eosin-stained formalin-fixed paraffin-embedded sinonasal tissue. Eotaxin-3, eosinophil peroxidase and immunoglobulin E levels were assessed using immunohistochemistry. Results: 38 participants were included (51.7 ± 15.6 years, 47.4% female), of whom 36.8% were diagnosed with CCAD and 63.2% with eCRS. The eCRS group was characterised by older age (55.8 ± 16.3 vs 44.5 ± 11.8 years, p = 0.029), and on histology exhibited a higher degree of tissue inflammation (τ b = 0.409, p = 0.011), greater proportion of patients with >100 eosinophils/high power field (87.5% vs 50%, p = 0.011), and higher absolute tissue eosinophil count (2141 ± 1947 vs 746 ± 519 cells/mm2, p = 0.013). Eotaxin-3 scores were higher in the eCRS group (5.00[5.00–6.00] vs 6.00[6.00–6.75], p = 0.015). Other outcomes were similar. Conclusions: Eosinophil and eotaxin-3 levels were elevated in eCRS compared with CCAD, suggesting a greater degree of eosinophil stimulation and chemotaxis. Patients with CCAD were younger. Future investigation and biomarkers may better distinguish CRS subpopulations. [ABSTRACT FROM AUTHOR]

Background Eosinophilic chronic rhinosinusitis (eCRS) is linked with skewed T-helper 2 or immunoglobulin E (IgE)-mediated allergic responses, with differing diagnosis, prognosis, and management to non-eCRS. Objective The association between biomarkers and eCRS was investigated to assess the predictors of eCRS. Methods A cross-sectional study of adult patients with chronic rhinosinusitis (CRS) undergoing endoscopic sinus surgery was conducted. eCRS was defined by histopathological assessment showing >10 eosinophils/high-power field on sinus mucosal biopsy. Blood tests were performed preoperatively and assessed for a full blood count including eosinophils and a white cell count (WCC) as well as biochemical markers of inflammation and atopy including Immunoglobulin E (IgE), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and ImmunoCAP testing for serum-specific IgE. Comparisons between eCRS and non-eCRS patients were performed. Results 345 patients (48.1% female, age 48.72 ± 15.06 years) were recruited, with 206 (59.7%) identified as eCRS, 41% with asthma and 47% CRS with nasal polyps. eCRS patients were more likely to have asthma (P < .01) and nasal polyps (P < .01). Blood eosinophils were significantly elevated in eCRS (0.42±0.34 vs 0.17±0.13 × 109/L, P < .01) as were eosinophils as a ratio of WCC (6.21 ± 4.48 vs 2.55 ± 1.84, P < .01). ESR was decreased when compared with non-eCRS (8.1±7.87 vs 10.65±11.91, P = .03). Receiver operating characteristic curve analysis predicted high tissue eosinophilia at blood eosinophil levels above 0.24 × 109/L (sensitivity 70.9%, specificity 78.4%, area under the curve [AUC]: 0.792, P < .01). eCRS was predicted at eosinophil above 4.27% of total WCC (sensitivity 64.1%, specificity 88.5%, AUC 0.797; P < .01; positive predictive value 89.2%, negative predictive value 62.4%, positive likelihood ratio 5.57, and diagnostic odds ratio 13.71). There was no significant association among WCC, CRP, IgE, or ImmunoCAP testing. Conclusion eCRS is associated with elevated blood eosinophils (>0.24 × 109/L), eosinophil ratio (>4.27% of total WCC), and lower ESR when compared with non-eCRS. [ABSTRACT FROM AUTHOR]

Background: Retromaxillary air cells (RMC) are posterior ethmoid cells that separate the maxillary and ethmoid sinuses. The clinical significance of these cells in contributing to revision functional endoscopic sinus surgery (FESS) is unknown. Objectives: To investigate the prevalence, anatomic dimensions, and radiographic characteristics of RMC in patients with recalcitrant chronic rhinosinusitis after previous FESS. Methods: A retrospective review of patients who underwent revision FESS at a tertiary medical center between January 1, 2012, and December 31, 2014. Computed tomographies of patients who underwent revision FESS, including posterior ethmoidectomies, were reviewed. Each side of the scan was assessed for residual RMCs. The radiographic dimensions and Lund-Mackay (LM) scores of these cells were recorded. Results: Sixty-nine patients who underwent revision FESS were identified. The median age of the patient population was 51 years (range, 21-79 years). Forty-two percent of the patients had nasal polyps. The mean number of previous FESS was 2 (range, 1-10). Incompletely dissected RMCs were identified in 101 of 138 analyzed sides (73%), despite documented previous posterior ethmoidectomies. Sixty-five percent of RMCs had an LM score of ≥1; RMCs of patients with polyps were more likely to have an LM score of 2 (p = 0.049). There was a significant correlation between the number of previous FESS procedures and whether the RMCs had been dissected (p = 0.010). There also was a significant correlation between RMC height and the number of previous FESS procedures (p = 0.015). Conclusion: RMCs seemed to often be undissected during primary FESS and, thus, were commonly encountered in revision FESS. The majority of analyzed cells in this cohort demonstrated an LM score of ≥1, which indicated that these cells frequently harbor residual diseased mucosa that may contribute to the need for revision surgery. [ABSTRACT FROM AUTHOR]

Background: Surgical landmarks for defining the level of the skull base during endoscopic sinus and skull base surgery (ESBS), e.g., the middle turbinate, may be distorted by tumor or previous surgery. The orbital floor is a valid fixed anatomic landmark for the white population, but it is not known if its use is useful for an Asian population. Objectives: To define fixed anatomic landmarks for ESBS in an Asian population and to compare the level of the skull base and its relation with anatomic landmarks between Asian and white populations. Methods: Computed tomographies performed on paranasal sinuses of Thai patients were retrospectively assessed. The distance between the nasal floor to four structures, the orbital floor, sphenoid planum, cribriform, and ethmoid roof, were measured. The level of skull base related to the orbital floor of an Asian population was compared with data of a white population from a previously published study. Results: A total of 150 Thai patients (300 paranasal sinus systems) were assessed and compared with 150 white patients. The orbital floor was always below the skull base (600 sides [100%]). When compared with white patients, the Asian patients had significantly higher mean (standard deviation [SD]) values: orbital floor (35.2 ± 3.4 mm versus 33.9 ± 3.0 mm; p < 0.001), ethmoid roof (49.3 ± 3.8 mm versus 48.4 ± 4.5 mm; p = 0.01), cribriform (46.4 ± 3.6 mm versus 44.0 ± 3.7 mm; p < 0.001), and sphenoid roof (45.7 ± 3.7 mm versus 44.9 ± 3.7 mm; p = 0.01). The Asian population had a mean (SD) longer distance from the orbital floor to the cribiform (11.2 ± 2.5 mm versus 10.1 ± 2.7 mm; p < 0.001), a shorter distance to the sphenoid roof (10.5 ± 3.3 mm versus 11.0 ± 2.9 mm; p = 0.03), and a similar distance to the ethmoid roof (14.1 ± 3.1 mm versus 14.5 ± 3.5 mm; p = 0.09). Conclusion: Although a statistical difference exists between racial groups, clinically, the orbital floor is a useful fixed anatomic landmark for ESBS for both Asian and white populations. [ABSTRACT FROM AUTHOR]

An understanding of paranasal sinus anatomy based on important fixed landmarks rather than variable anatomy is critical to ensure safe and complete surgery. The concept of the paranasal surgical box defines the anatomic limits of dissection. The boundaries of the surgical box include the middle turbinate medially, orbital wall laterally, and skull base superiorly. The "vertical component" of the surgical box defines the boundaries of the frontal recess and includes the middle turbinate and intersinus septum medially, medial orbital wall and orbital roof laterally, nasofrontal beak anteriorly, and skull base and posterior table of frontal sinus posteriorly. The paranasal sinuses are divided into anterior, posterior, and sphenoidal functional cavities based on their distinct drainage pathways into the nose. The ultimate goal of surgery is to create afunctional sinus cavity. Application of the paranasal surgical box and its vertical component enables the surgeon to view the limits of dissection with a single position of the endoscope. This will ensure complete dissection of the functional sinonasal compartments and effectively avoid leaving behind disconnected cells from the surgical cavity, mucocele formation, mucous recirculation, overcome obstructive phenomenon and enable maximal delivery of topical therapy in the post-operative setting. This article reviews the structure and function of the nasal cartilages and turbinates. It also describes the concept of the paranasal surgical box, key anatomical landmarks and limits of dissection. Normal anatomy and common variants of normal anatomy are discussed. [ABSTRACT FROM AUTHOR]

Background: The identification of anatomic landmarks in endoscopic skull base or revision sinus surgery can be challenging. Normal anatomy is significantly altered with many paranasal tumors. Traditional endoscopic surgical landmarks extrapolated from inflammatory disease, such as the superior turbinate, may have been previously removed or involved in pathology. A frequently used rule to enter the sphenoid, “stay below or at the level of the orbital floor as dissection proceeds posteriorly and one will avoid the skull base,” is assessed anatomically. Methods: The maxillary sinus roof height, relative to the nasal floor, was assessed as an operative landmark. Computed tomography (CT) performed on paranasal sinuses was studied. The relative height, ratio, and proportions of the maxillary sinus, ethmoid roof, cribriform fossa, and sphenoid planum were measured using computerized assessments. Results: Three hundred paranasal sinus systems were evaluated. The roof of the maxillary sinus was below the level of the skull base in 100% relative to the cribriform and 100% relative to the sphenoid planum. The mean distance of the maxillary roof below the skull base was 10.1 ± 2.7 mm for the cribriform and 11.0 ± 2.9 mm for the sphenoid. Conclusion: The maxillary sinus roof can be used as a robust landmark to allow safe dissection and debulking of pathology. Pathology removal can proceed posterior with this landmark to enable a safe entry to the sphenoid sinus, and thus the true skull base, when normal structures such as the superior turbinate and ostium are not available. [ABSTRACT FROM AUTHOR]

Objective: Persistent pneumocephalus often indicates the presence of a skull base (SB) defect associated with one of the paranasal sinuses. Such defects require treatment to avoid sequelae. The study objective was to evaluate success in endoscopic closure of SB defects associated with pneumocephalus. Design: Retrospective medical record review. Setting: Tertiary care academic rhinology practice. Methods: A 5-year retrospective review of patients presenting with pneumocephalus. Presenting symptoms, etiology of SB defects, radiologic findings, operative techniques, and follow-up were evaluated. Main Outcome Measures: Success of endoscopic SB defect repair in the setting of pneumocephalus was assessed. Factors potentially contributing to failure were evaluated in appropriate cases. Results: Eleven patients with pneumocephalus from 14 SB defects underwent 17 endoscopic repairs. In 11 surgical procedures, active cerebrospinal fluid (CSF) leaks were identified, but in the remaining 6, pneumocephalus was present without CSF leak. Radiologic location of pneumocephalus ranged from extra-axial to diffuse within the brain parenchyma. SB defects were identified using fine-cut computed tomographic (CT) scans, CT cisternograms, and intrathecal fluorescein. Defects were located in the sphenoid, sella, ethmoid roof, and frontal sinus posterior table. Eight of 11 patients (72%) were managed with endoscopic repair alone. Factors potentially effecting failure included malignancy, previous radiation, intracranial infection, malnutrition, and Cushing disease. Conclusions: Endoscopic SB defect repair for pneumocephalus is largely successful. Localization of SB defects in these cases is often assisted by CT cisternography and intrathecal fluorescein. [ABSTRACT FROM AUTHOR]

Background: Larger and more extensive lesions of the maxilla and infratemporal fossa are being successfully managed by entirely endoscopic approaches. There are still limitations in access, especially the anterolateral maxilla. The suitability of various surgical approaches was assessed in relation to surgical access achieved. Methods: Surgical access was compared in 10 cadaver heads. Five zones were defined: zone 1, nasal cavity; zone 2, medial to infraorbital nerve (ION); zone 3, lateral to ION; zone 4, anterior maxilla; and zone 5, premaxillary tissue. Endoscopic maxillary surgery consisted of standard antrostomy, modified medial maxillectomy, or complete medial maxillectomy with lacrimal duct resection. Transseptal and ipsilateral approaches were compared in each surgical state. The degree of angulations and resection zone accessed were recorded from image-guided surgery. The limits of both straight and curved instrumentation were also compared. Results: Transseptal access improved surgical access by 14.7 ± 2.5° when compared with ipsilateral approaches (p < 0.001) across all situations. The access to zone 3 across all specimens was significantly improved by 63.3-97.6% (χ2 = 20.83; p < 0.001) after all three surgical states. After complete medial maxillectomy, access to zone 4 increased from 25.0 to 85.0% (χ2 = 14.54; p < 0.001) with a transseptal approach. Conclusion: Extended endoscopic maxillary surgery combined with a transseptal option enables additional access to previously considered challenging locations. Preoperative assessment of skull base tumor, papilloma and angiofibroma extent, and resection margin will dictate surgical approach. [ABSTRACT FROM AUTHOR]

Background: Endoscopic repair of skull base (SB) defects is successful in over 90% of cases. Certain factors may contribute to failure of SB repair techniques or need for secondary repair. Methods: Five-year retrospective review of endoscopic SB defect repairs performed by a single surgeon. Results: Eighty-nine patients undergoing 110 procedures to repair 97 SB defects were evaluated. Etiology of defects included surgical/iatrogenic (64%), spontaneous (17%), traumatic (12%), congenital (6%), and idiopathic (1%). Defects occurred in the sella (41%), sphenoid sinus (18%), ethmoid roof (17%), olfactory cleft (16%), frontal sinus/recess (6%), and middle cranial fossa (2%). Sixty-three patients (71%) underwent primary SB defect repair and 26 patients underwent secondary repair (29%). In revision cases, mean number of prior repair attempts was 1.5 (range, 1-4). Factors potentially contributing to need for secondary SB defect repair included inability to localize SB defect (p =0 .008), development of new SB defect, prior sinus or SB surgery (p < 0.001), prior craniotomy (p < 0.001), prior radiation therapy (p = 0.002), and intracranial infection (p = 0.023). SB defects were successfully closed in 83 patients overall (93%), with success achieved in 97% of primary patients and 85% of secondary patients. Of failures, 3 patients required craniotomy for defect closure, 2 patients underwent permanent cerebrospinal fluid (CSF) diversion, and 1 patient has persistent CSF rhinorrhea. Conclusion: Although endoscopic repair of SB defect remains largely successful, certain factors should alert the surgeon to the potential for failure of repair or need for secondary SB defect repair. [ABSTRACT FROM AUTHOR]

Background: Sinonasal care after endoscopic tumor resection aims to manage crusting, edema, mucus, and a healing cavity. High-volume irrigations have proved beneficial in this setting. The addition of corticosteroid to the irrigation is used for chronic rhinosinusitis (CRS) in modifying the postsurgical inflammatory response; however, its effect in endoscopic sinonasal tumor resection is unknown. Saline alone versus combination saline and corticosteroid irrigations in postoperative nasal care of sinonasal tumor patients was assessed. Methods: A retrospective cohort of patients postendoscopic endonasal tumor resection was assessed. Patients used 240 mL of saline or 240 mL of saline with 1 mg of betamethasone daily. Nasal symptom scores (NSSs) and the 22-item Sino-Nasal Outcome test (SNOT-22) was recorded 3 months postoperatively. An endoscopic score was made of the area undergoing secondary healing at 3 months by two blinded assessors. Results: Fifty-nine patients were assessed (aged 50.1 ± 18.26 years; 36% female subjects). The groups were similar in number (saline n = 31), treatment, and surgical characteristics. The endoscopic scores did not differ between the groups at 3 months. NSS was lower in the saline group (1.0 [interquartile range {IQR}, 3] versus 7.0 [IQR, 9]; p = 0.03) and, similarly, for SNOT-22 (0.24 [IQR, 1] versus 1.09 [IQR, 1]; p = 0.01) compared with the saline with steroid group. Conclusion: Although corticosteroid irrigations have become routine for managing inflammatory sinus disease at our center, their use after tumor surgery does not appear to be warranted. The inflammatory healing process after tumor surgery differs from CRS inflammation and may explain the observed findings. [ABSTRACT FROM AUTHOR]