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OBJECTIVE Suprasellar meningioma resection via either the transcranial approach (TCA) or the endoscopic endonasal approach (EEA) is an area of controversy and active evaluation. Skull base surgeons increasingly consider patient-reported outcomes (PROs) when choosing an approach. No PRO measure currently exists to assess quality of life for suprasellar meningiomas. METHODS Adult patients undergoing suprasellar meningioma resection between 2013 and 2019 via EEA (n = 14) or TCA (n = 14) underwent semistructured interviews. Transcripts were coded using a grounded theory approach to identify themes as the basis for a PRO measure that includes all uniquely reported symptoms. To assess content validity, 32 patients and 15 surgeons used a Likert scale to rate the relevance of items on the resulting questionnaire and the general Patient-Reported Outcomes Measurement Information System–29 (PROMIS29). The mean scores were calculated for all items and compared for TCA versus EEA patient cohorts by using unpaired t-tests. Items on either questionnaire with mean scores ≥ 2.0 from patients were considered meaningful and were aggregated to form the novel Suprasellar Meningioma Patient-Reported Outcome Survey (SMPRO) instrument. RESULTS Qualitative analyses resulted in 55 candidate items. Relative to patients who underwent the EEA, those who underwent the TCA reported significantly worse future outlook before surgery (p = 0.01), tiredness from medications 2 weeks after surgery (p = 0.001), and word-finding and memory difficulties 3 months after surgery (p = 0.05 and < 0.001, respectively). The items that patients who received a TCA were most concerned about included medication-induced lethargy after surgery (2.9 ± 1.3), blurry vision before surgery (2.7 ± 1.5), and difficulty reading due to blurry vision before surgery (2.7 ± 2.7). Items that patients who received an EEA were most concerned about included blurry vision before surgery (3.5 ± 1.3), difficulty reading due to blurry vision before surgery (2.4 ± 1.3), and problems with smell postsurgery (2.9 ± 1.3). Although surgeons overall overestimated how concerned patients were about questionnaire items (p < 0.0005), the greatest discrepancies between patient and surgeon relevance scores were for blurry vision pre- and postoperatively (p < 0.001 and < 0.001, respectively) and problems with taste postoperatively (p < 0.001). Seventeen meningioma-specific items were considered meaningful, supplementing 8 significant PROMIS29 items to create the novel 25-item SMPRO. CONCLUSIONS The authors developed a disease- and approach-specific measure for suprasellar meningiomas to compare quality of life by operative approach. If demonstrated to be reliable and valid in future studies, this instrument may assist patients and providers in choosing a personalized surgical approach.

Hemorrhagic hereditary telangiectasia (HHT) is a rare autosomal dominant disorder that causes multisystem vascular malformations including mucocutaneous telangiectasias and arteriovenous malformations (AVMs). Clinical and genetic screening of patients with signs, symptoms, or a family history suggestive of HHT is recommended to confirm the diagnosis on the basis of the Curaçao criteria and prevent associated complications. Patients with HHT frequently have epistaxis and gastrointestinal bleeding from telangiectasias. Pulmonary AVMs are common right-to-left shunts between pulmonary arteries and veins that can result in dyspnea and exercise intolerance, heart failure, migraine headaches, stroke or transient ischemic attacks, brain abscesses, or in rare cases, pulmonary hemorrhage. Primary neurologic complications from cerebral AVMs, which can take on many forms, are less common but particularly severe complications of HHT. Multimodality imaging, including transthoracic echocardiography, Doppler US, CT, and MRI, is used in the screening and initial characterization of vascular lesions in patients with HHT. Diagnostic angiography is an important tool in characterization of and interventional treatments for HHT, particularly those in the lungs and central nervous system. A multidisciplinary approach to early diagnosis, treatment, imaging, and surveillance at high-volume HHT Centers of Excellence is recommended. Although a variety of idiopathic, traumatic, or genetic conditions can result in similar clinical and imaging features, the Curaçao criteria are particularly useful for the proper diagnosis of HHT. Imaging and treatment options are reviewed, with a focus on screening, diagnosis, and posttreatment findings, with the use of updated international guidelines.

Background As rhinology fellowship positions outpace the availability of academic rhinology jobs, it is increasingly important to identify characteristics that are associated with academic placement after fellowship completion. In this study, we evaluated the association of academic characteristics during training with current job placement and posttraining scholarly impact. Methods Previous rhinology fellows were identified using publicly available data. Bibliometric indices, training institutions, graduate degrees, and job placement data were used in bivariate and multivariable regression analyses to assess for association with predictors and academic trajectory. Results Data from 265 rhinologists, all graduating between 1991 and 2020, were included. Most surgeons (n = 185, 70%) held an academic position and 80 (30%) surgeons worked in a nonacademic setting; 93.2% had a Doctor of Medicine (MD) degree and 80.3% were male. Multivariable logistic regression indicated that a designation of MD, compared with Doctor of Osteopathic Medicine (DO; odds ratio [OR], 5.93; 95% confidence interval [CI], 1.97-21.9), number of publications during fellowship (OR, 1.19; 95% CI, 1.02-1.41), and h-index during training (OR, 1.25; 95% CI, 1.07-1.49]) were independently predictive of academic job placement. Meanwhile, number of primary authorships during fellowship (β = 1.47; 95% CI, 1.07-1.88]), h-index during training (β = 0.48; 95% CI, 0.25-0.71), and PhD (β = 4.16; 95% CI, 1.57-6.76) were associated with posttraining h-index. Medical school ranking; graduate degrees, including Master of Science (MS), Master of Business Administration (MBA), and Master of Public Health (MPH); and research metrics before residency were not associated with either academic placement or posttraining h-index. Conclusion The predictors of academic job placement in rhinology are unclear, but h-index during training, and research productivity during fellowship may serve as indicators of an academic career.

Background The management of paranasal sinus and nasal cavity malignancies has evolved significantly with the development of advanced endoscopic techniques and improvements in adjuvant therapy. We sought to characterize both disease-specific survival (DSS) and 5-year conditional disease-specific survival (CDSS, the change in life expectancy with increasing survivorship) for sinus malignancies diagnosed before and after the year 2000. Methods Patients diagnosed with sinus and nasal cavity cancer between 1973-2015 were extracted from the Surveillance, Epidemiology, End Results (SEER) registry. Kaplan-Meier analysis for DSS was stratified by year of diagnosis before and after 2000. Cox-proportional hazards models of DSS controlling for stage, age, and year of diagnosis were generated. CDSS was calculated using Cox-regression models stratified by stage. Results We analyzed 10,535 patients. Diagnosis after the year 2000 was independently associated with improved DSS (HR:0.81, 95% CI: 0.75-0.87, P Conclusion For paranasal sinus and nasal cavity malignancies, year of diagnosis independently influences both DSS and CDSS. Improved survival is likely due to advances in both surgical and adjuvant treatments. To our knowledge, this study is the first to examine CDSS for these malignancies.

Background Evidence suggests chemosensory dysfunction (CSD) patients have altered diet, but population-level evidence assessing diet quality in CSD patients is lacking. Objective We examined the association between CSD and diet quality in a representative sample of United States adults. Methods This cross-sectional study included 2831 adults aged greater than 40 years from the 2013-2014 National Health and Nutrition Examination Survey who completed the taste/smell questionnaire and examination. Mean nutrient intake in subjects with self-reported olfactory/gustatory dysfunction (sOD/sGD) and measured olfactory/gustatory dysfunction (mOD/mGD) were compared to those without CSD using univariate Wilcoxon rank-sum tests. The Healthy Eating Index (HEI), a validated measure of diet quality, was calculated. The proportion of subjects with CSD with bottom-quartile HEI was compared to those without CSD using multivariate logistic regression, adjusting for demographic and socioeconomic covariates. Results The population-weighted prevalence of sOD, sGD, mOD, and mGD was 20.1%, 14.4%, 15.9% and 25.6%, respectively. Subjects with mOD had lower mean intake of total calories, total fat, protein, sodium, and potassium compared to normal subjects (1873.4 ± 49.6 vs 2010.2 ± 24.2 kcal, 72.3 ± 2.7 vs 78.6 ± 1.0 gm, 74.0 ± 2.5 vs 80.4 ± 0.6 gm, 3122 ± 97.2 vs 3353.2 ± 37.0 mg, 2509.8 ± 69.8 vs 2684.7 ± 26.1 mg, P Conclusions This population-level study suggests an association between poor diet quality and variation in dietary intake in patients with CSD, which warrants further investigation and suggests the possible need for nutritional counseling for CSD patients.

BACKGROUND As endoscopic endonasal skull base surgery (EESBS) for sellar pathology has become routine, there is increasing awareness of quality-of-life (QOL) outcomes related to this approach. Similarly, there is a growing interest in postoperative chemosensory function, with notable emphasis on olfaction and the corresponding psychosocial implications of olfactory dysfunction. Meanwhile, there has been minimal direct investigation into gustatory outcomes, and the association between these 2 chemosensory functions remains poorly understood. OBJECTIVE To investigate patient-reported chemosensory function and rhinologic-specific QOL following EESBS for routine sellar pathologies. METHODS Comprehensive clinical characteristics and sinonasal QOL assessments, measured using Anterior Skull Base Nasal Inventory-12 (ASK Nasal-12), were collected from 46 patients undergoing EESBS for sellar pathology. RESULTS Forty-six patients were included: 65.2% female, average age 52.8 yr (range: 27-89). The most common pathology was nonfunctioning pituitary adenoma (n = 28). Preoperative ASK Nasal-12 scores (mean = 0.81) demonstrated postoperative worsening at 2 wk (mean = 2.52, P

Patients with chemosensory dysfunction experience significant quality of life disruptions, including reduced enjoyment of eating. While chemosensory dysfunction has been associated with eating disorders, the relationship is poorly understood. This systematic review aims to characterize psychophysical gustation and olfaction in patients with eating disorders. Systematic review of investigations assessing psychophysical chemosensory function in patients with organic eating disorders. 26 studies were included. Five studies assessed both chemosenses, while 12 and 9 assessed exclusively gustation or olfaction, respectively. In total, 779 patients were included [72.4% anorexia nervosa (AN), 26.7% bulimia nervosa (BN), 0.8% combined AN/BN]. Patients with eating disorders experienced rates of hypogeusia up to 87% in AN and 84.6% in BN. There was evidence for alterations in psychophysical olfaction, but orientation of trends were less clear. Chemosensory dysfunction was more evident in AN patients. Treatment correlated with improved chemosensory function. Despite heterogeneity in study methodology and results, this review demonstrates that patients with eating disorders experience some degree of chemosensory dysfunction, particularly in gustation. This symptomatology overlaps with those experienced by patients with other causes of chemosensory impairment. These findings suggest potential broad psychosocial, dietary, and mental health implications in patient populations experiencing chemosensory dysfunction. Level II.

Because of involvement of the optic apparatus, craniopharyngiomas frequently present with visual deterioration. Although visual improvement is a primary goal of surgical intervention, prediction models are lacking.We retrospectively reviewed all patients undergoing craniopharyngioma surgery at a single institution (2014-2019). Preoperative, intraoperative, and postoperative variables of interest were collected. Visual acuity and visual fields (VFs) were standardized into Visual Impairment Scores (VISs), defined by the German Ophthalmological Society. VIS ranged from 0 (normal vision) to 100 (complete bilateral blindness). Visual improvement/deterioration was defined as a postsurgical decrease/increase of ≥5 VIS points, respectively.Complete ophthalmologic assessments were available for 61 operations, corresponding to 41 patients (age, 4-73 years). Vision improved after 28 operations (46%), remained stable after 27 (44%), and deteriorated after 6 (10%). In bivariate analysis, significant predictors of visual improvement included worse preoperative VIS (odds ratio [OR], 1.058; P0.001), worse preoperative VF mean deviation (OR, 1.107; P = 0.032), preoperative vision deficits presenting for longer than 1 month (OR, 6.050; P = 0.010), radiographic involvement of the anterior cerebral arteries (OR, 3.555; P = 0.019), and gross total resection (OR, 4.529; P = 0.022). The translaminar surgical approach was associated with visual deterioration (OR, 6.857; P = 0.035). In multivariate analysis, worse preoperative VIS remained significantly associated with postoperative visual improvement (OR, 1.060; P = 0.011). Simple linear correlation (RPatients with reduced preoperative vision, specific radiographic vascular involvement, and gross total resection showed increased odds of visual improvement, whereas the translaminar approach was associated with visual deterioration. Such characteristics may facilitate patient-surgeon counseling and surgical decision making.

BACKGROUND Rhinologic disease can be responsible for systemic symptoms affecting mood, cognition, and sleep. It is unclear whether sleep disturbance in specific rhinologic disorders (chronic rhinosinusitis [CRS], rhinitis, and nasal septal deviation [NSD]) is an obstructive phenomenon or due to other mechanisms. In this review we examine the impact of CRS, rhinitis, and NSD on objective and subjective sleep outcome metrics and draw comparisons to normal controls and patients with known obstructive sleep apnea (OSA). METHODS A systematic review of 4 databases (PubMed, Scopus, Cochrane Library, and Web of Science) was performed. Studies reporting on objective (apnea-hypopnea index [AHI], respiratory disturbance index [RDI], oxygen nadir) and subjective (Epworth Sleepiness Scale [EpSS], Pittsburgh Sleep Quality Index [PSQI], Fatigue Severity Scale [FSS]) sleep parameters and disease-specific patient-reported outcome measures (PROMs; 22-item Sino-Nasal Outcome Test [SNOT-22], Rhinoconjunctivitis Quality of Life Questionnaire [RQLQ], Nasal Obstruction Symptom Evaluation [NOSE]) were included. RESULTS The database search yielded 1414 unique articles, of which 103 were included for analysis. Baseline PROMs were at the high end of normal to abnormal for all 3 conditions: EpSS: CRS (9.8 ± 4.0), rhinitis (9.7 ± 4.3), and NSD (8.9 ± 4.6); and PSQI: CRS (11.0 ± 4.5), rhinitis (6.1 ± 3.7), and NSD (8.6 ± 3.5). Objective measures demonstrated a mild to moderate OSA in the studied diseases: AHI: CRS (10.4 ± 11.5), rhinitis (8.6 ± 8.8), and NSD (13.0 ± 6.9). There were significant differences when compared with reported norms in all measured outcomes (p < 0.001). CONCLUSION Sleep quality is impacted by rhinologic (CRS, rhinitis, NSD) disease. There is likely a mild obstructive component contributing to poor sleep, but other contributing factors may be involved.

BACKGROUND Olfaction and gustation are associated with age-related decline. Deficits in these chemosenses have been associated with significant comorbidities. Meanwhile, frailty, defined as a reduced physiological reserve, is well correlated with mortality and worse health outcomes. We sought to analyze a nationally representative patient population to determine the association between chemosensory dysfunction and frailty. METHODS Cross-sectional analysis of U.S. National Health and Nutrition Examination Survey (NHANES) 2013-2014 was performed, using multivariate logistic regression to examine the association between chemosensory dysfunction and frailty in adults aged ≥40 years (n = 3547). Self-reported olfactory dysfunction (sOD) and gustatory dysfunction (sGD), and measured olfactory dysfunction (mOD) and gustatory dysfunction (mGD) were assessed for all participants. Frailty was operationalized using a 39-item frailty index (FI) and stratified into 4 groups using validated cutoffs. RESULTS Participants with sOD and mOD had significantly higher mean FI scores (sOD: 0.18 vs 0.13, p < 0.001; mOD: 0.20 vs 0.14, p < 0.001), whereas subjects with sGD, but not mGD, had higher mean FI scores (sGD: 0.21 vs 0.13, p < 0.001; mGD: 0.14 vs 0.14, p = 0.953). Multivariate logistic regression demonstrated frail participants had significantly greater odds of sGD (odds ratio [OR] 4.11; 95% confidence interval [CI], 3.46 to 4.88), sOD (OR 2.35; 95% CI, 1.98 to 2.78), and mOD (OR 1.58; 95% CI, 1.22 to 2.05), but not mGD (OR 1.21; 95% CI, 0.91 to 1.61). This association was strongest in the frailest group. CONCLUSION Self-reported chemosensory dysfunction and mOD are independently associated with measures of frailty, suggesting a novel method to assess or predict frailty.

Background Olfactory dysfunction (OD) has been reported to impact social interactions. However, the relationship between OD and loneliness has received little attention. The purpose of this study was to determine the association between OD and loneliness, controlling for patient factors. Methods Subjects without otolaryngic complaints were enrolled and olfactory function was assessed using: Sniffin’ Sticks test to measure threshold, discrimination and identification (TDI), Questionnaire of Olfactory Disorders Negative Statements (QOD-NS) and 9 – item Olfactory-Visual Analogue Scale (VAS). Loneliness was assessed using the De Jong Gierveld (DJG) and University of California Los Angeles (UCLA) loneliness scales. Bivariate analysis was performed followed by regression analysis, controlling for confounders. Results In total, 221 subjects were included with a mean age of 50.5 years (range 20 to 93), 133 (60.2%) females and 161 (72.9%) white. Mean TDI score was 29.3 (7.0) and 49.5% of the cohort was dysosmic. Using DJG, 36.4% of the cohort were classified as lonely, whereas 35.0% were lonely using UCLA. Olfactory measures were significantly associated with DJG, including TDI (β = −0.03, p = 0.050), olfactory discrimination (β = −0.111, p = 0.005), QOD-NS (β = 0.058, p Conclusions In this community-based sample of older adults, both OD and loneliness were common. Those subjects with worse olfactory function were more likely to report loneliness. Further research is necessary to establish causality, as well as explore the role of depression.

Background Viral respiratory tract infections are associated with a significant burden of disease and represent one of the leading causes of mortality worldwide. The current Coronavirus Disease 2019 (COVID-19) pandemic highlights the devastating toll that respiratory viruses have on humanity and the desperate need to understand the biological characteristics that define them in order to develop efficacious treatments and vaccines. To date, Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has infected nearly 600 times more people and resulted in 200 times more deaths relative to Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV) and Middle Eastern Respiratory Syndrome Coronavirus (MERS-CoV) combined. Objective Through this review, we aim to summarize the key characteristics of respiratory viruses that hold global significance, with a focus on SARS-CoV-2. Our goal is to disseminate our current knowledge of these infectious agents to otolaryngologists, in particular rhinologists, practicing in the COVID-19 era. Methods The general and clinical characteristics of selected respiratory viruses along with available viral treatments and vaccines are reviewed. Results There has been significant progress in our understanding of the epidemiology and pathogenesis of various respiratory viruses. However, despite the advancement in knowledge, efficacious vaccines and antiviral treatments remain elusive for most respiratory viruses. The dire need for these scientific discoveries is highlighted by the recent COVID-19 pandemic, which has prompted investigators worldwide to conduct clinical trials at an accelerated timeline in an effort to reduce the morbidity and mortality associated with SARS-CoV-2 infection. Rhinologists will continue to remain on the front-lines of pandemics associated with respiratory viruses. Conclusion In light of these unprecedented times, the need to understand the nuances of these viral respiratory pathogens, especially SARS-CoV-2, cannot be overemphasized. This knowledge base is of particular importance to otolaryngologists, whose expertise in the upper airway coincides with the anatomic tropism of these infectious agents.

OBJECTIVES Patients with chronic rhinosinusitis (CRS) often describe alterations in sense of taste. These complaints have historically been attributed to olfactory dysfunction; however, there is evidence of direct, objective, gustatory disturbances in the setting of CRS that are not thoroughly characterized. This study sought to investigate and summarize gustatory dysfunction experienced by patients with CRS. METHODS PubMed, EMBASE, Cochrane Library, Web of Science, and Scopus databases were reviewed following PRISMA guidelines. English language, original studies investigating objective taste in adult patients with CRS were included. A meta-analysis with inverse variance, random-effects model was performed. RESULTS Of 2750 studies screened, 11 articles with 471 unique patients were included. Patients with CRS exhibit worse gustatory function compared to healthy controls (standardized mean difference 0.94 [95% CI, 0.44-1.45]). Hypogeusia was identified in 32/95 (33.7%) patients from three studies that used methods with a validated definition of hypogeusia. Older age, male gender, and smoking history were associated with taste dysfunction, while objective gustatory and olfactory dysfunction were not correlated. Subjective taste and quality of life measures were also not associated with objective taste. The impact of sinus surgery on objective taste is unclear. CONCLUSION Approximately 34% of patients with CRS experience hypogeusia. Neither olfactory function nor subjective taste were associated with objective gustatory function. Given the substantial prevalence of taste dysfunction patients with CRS, there is significant potential for growth in understanding of pathogenesis, impact on quality of life, and potential treatment strategies of taste impairment in the CRS patient population. LEVEL OF EVIDENCE 1 Laryngoscope, 131:482-489, 2021.

Background Allergic fungal rhinosinusitis (AFRS) is disproportionately identified in patients of low socioeconomic status living in warm, humid climates, and is thought to occur in response to environmental fungal species. Objective We hypothesized that micro-geographic differences in fungal exposure contribute to the pathogenesis of AFRS, and compared home fungal exposure of patients with AFRS to normative data and controls. Methods Comprehensive prospective enrollment and data capture was completed in 70 patients. Patients with AFRS were compared to a control population with chronic rhinosinusitis with nasal polyposis (CRSwNP) and comorbid atopy. Comprehensive demographics, 22-item sino-nasal outcomes test (SNOT-22) questionnaires, and endoscopy scores were compiled. Using a test strip collection system, a home fungal assessment was completed for each patient, along with detailed questions related to home condition. Results Patients with AFRS were more likely to be younger (pConclusion This study failed to detect differences in total home fungal exposure levels between those with AFRS and atopic CRSwNP, despite differences in socioeconomic status. This suggests that absolute fungal levels may not be the primary driver in development of AFRS, or that the fungal detection strategies utilized were not representative of patients’ overall fungal exposure.

The treatment paradigm for the management of chronic rhinosinusitis with nasal polyposis (CRSwNP) is currently undergoing a rapid evolution with the development of monoclonal antibody therapies targeted at type 2 inflammatory pathways. The use of these biologic therapies in asthmatic patients, and more recently, patients with CRSwNP has produced promising results, especially for patients with severe disease. Many questions regarding the appropriate timing of these medications, whether or not these new treatment strategies should be used as a monotherapy or in conjunction with traditional therapies such as sinus surgery, the role of appropriate phenotyping, and identification of biomarkers, remain unanswered. We herein present a case of a patient with severe eosinophilic asthma and comorbid CRSwNP who failed to achieve control of his respiratory symptomology and ultimately progressed to sinus surgery despite treatment with an anti-interleukin 5 monoclonal antibody therapy (mepolizumab). Consideration is given to the mechanistic underpinnings of the reported patient's failure. This case highlights the need for further understanding of the optimal usage of these novel therapeutics in the management of CRSwNP and in the need to better understand the pathophysiology of CRSwNP.

Olfactory dysfunction (OD) is one of the cardinal symptoms of chronic rhinosinusitis (CRS), and its prevalence ranges from 60% to 80% in patients with CRS. It is much more common in CRS with nasal polyposis patients compared to CRS without nasal polyposis. Decreased olfactory function is associated with significant decreases in patient-reported quality of life (QOL), and notably, depression and the enjoyment of food. Objective measures can help detail the degree of OD, whereas subjective measures can help to determine in the impact on patient. There is variable treatment response to OD with both medical and surgical therapies.

Endoscopic endonasal skull base surgery (EESBS) has many advantages compared with traditional approaches. Recently, there is an increasing focus on patient-centered, quality of life (QOL), and approach-specific outcomes. This review seeks to illuminate our current understanding and knowledge gaps in EESBS-specific QOL outcomes. In an effort to capture the most relevant QOL implications for patients undergoing EESBS, three comprehensive, validated, QOL instruments have been created. These instruments are often supplemented by sinonasal-specific outcome measures, given the potentially significant sinonasal repercussions incurred with the use of the endonasal corridor. To date, most EESBS QOL investigations include patients with sellar-based pathology, though series with patients undergoing more extensive approaches are emerging. Generally, patients experience transient postoperative worsening of skull base– and sinonasal-specific QOL. Larger series, with validated QOL outcome measures, are needed to better understand patient outcomes and the morbidities of EESBS, especially those that relate to olfaction and surgery beyond the sella.

OBJECTIVE Balloon sinuplasty (BSP) is associated with varied practice patterns. This study sought to identify otolaryngologist characteristics associated with BSP utilization. STUDY DESIGN Retrospective analysis of Medicare claims data and the National Physician Compare database. METHODS Outlier otolaryngologists were compared to non-outliers. Otolaryngologist characteristics included sex, practice size, geographic setting, years of experience, procedure setting, 10 or fewer endoscopic sinus surgeries per year for 3 or more years, and high number of services per unique Medicare beneficiary. Outlier status was defined as performing an annual total of balloon procedures of 2 standard deviations (SDs) above the mean for all otolaryngologists in the same year. RESULTS Between January 2012 and December 2017, 1,408 otolaryngologists performed 101,662 endoscopic sinus surgeries and 97,680 BSP procedures. Sixty-six outlier otolaryngologists (4.7%) accounted for 44.3% of all BSP procedures. Outlier status was associated with practice size of 10 or fewer individual providers (OR, 5.15; 95% CI, 2.73-9.74; P

To determine the impact of treatment for patients with nasal obstruction secondary to allergic rhinitis (AR) and nasal septal deviation (NSD) on sleep quality.Primary studies were identified though PubMed, Scopus, Cochrane Library, and Web of Science.A systematic review was performed by querying databases for articles published through August 2020. Studies were included that reported on objective sleep parameters (apnea-hypopnea index) and sinonasal and sleep-specific patient-reported outcome measures: Rhinoconjunctivitis Quality of Life Questionnaire, Nasal Obstruction Symptom Evaluation, Epworth Sleepiness Scale (EpSS), and Pittsburgh Sleep Quality Index (PSQI).The database search yielded 1414 unique articles, of which 28 AR and 7 NSD studies were utilized for meta-analysis. A total of 9037 patients (8515 with AR, 522 with NSD) were identified with a mean age of 35.0 years (35.3 for AR, 34.0 for NSD). Treatment for AR and NSD significantly improved subjective sleep quality. For AR, the EpSS mean difference was -1.5 (95% CI, -2.4 to -0.5;Subjective sleep quality significantly improved following treatment for AR and NSD. There were insufficient data to demonstrate that objective metrics of sleep quality similarly improved.

Despite the increasing utility of the endoscopic endonasal approach (EEA) for management of anterior skull base (ASB) pathologies, the optimal treatment strategy for olfactory groove meningiomas (OGM) remains unclear. This project sought to systematically compare outcomes of EEA management with conventional transcranial approach (TCA) for the treatment of OGMs. A systematic review was performed to identify studies that compared outcomes following EEA and TCA for OGMs. Data extracted from each study included gross total resection (GTR), incidence of cerebrospinal fluid (CSF) leaks, and post-operative complications including anosmia. The results of the search yielded 5 studies which met the criteria for inclusion and analysis. All studies compared TCA (n = 922) with EEA (n = 141) outcomes for OGMs. Overall, the rate of gross total resection (GTR) was lower among the endoscopic group (70.9%) relative to the transcranial group (91.5%). The rate of post-operative CSF leak was 6.3% vs. 25.5% for the transcranial and endoscopic groups, respectively. Post-operative anosmia was higher for patients undergoing EEA (95.9%) compared with patients in the transcranial group (37.4%). In this analysis, EEA was associated with a lower rate of GTR and higher incidences of CSF leaks and post-operative anosmia. However, with increasing surgeon familiarity of the endoscopic anatomy and technique for managing ASB pathologies, a nuanced approach may be used to minimize patient morbidity and widen the spectrum of skull base surgery.

BACKGROUND Spontaneous skull base defects can result in life-threatening intracranial complications (ICCs), including meningitis and pneumocephalus. Endoscopic skull base reconstruction (ESBR) has traditionally been the treatment of choice, but its impact upon ICCs is not known. In this study, we aimed to describe the incidence rate of preoperative ICCs in patients with spontaneous skull base defects, risk factors associated with ICC development, and the impact of surgical repair on the incidence rate of ICCs. METHODS A retrospective review was performed of all spontaneous skull base defects undergoing ESBR from 2005 to 2019 at 2 academic tertiary care medical centers. The incidence rate of ICCs and the demographics information and risk factors were collected. RESULTS In 222 spontaneous skull base defects, preoperative ICCs occurred in 46 subjects (20.7%) with an incidence rate of 22.7 per 100 person-years. Factors significantly associated with preoperative ICCs included symptom duration, reduced body mass index (BMI), resolved cerebrospinal fluid rhinorrhea, and location in the frontal or lateral sphenoid sinuses. Endoscopic repair was successful in 97.2% of subjects and the postoperative ICC incidence rate was significantly reduced at 0.8 per 100 person-years (p < 0.001). CONCLUSION Spontaneous skull base defects pose significant risk for life-threatening ICCs. Our findings reveal significantly elevated odds of ICC development associated with resolved CSF rhinorrhea, lower BMI, longer duration of symptoms, and defect location. Endoscopic repair is highly successful with low morbidity and significantly reduces the incidence rate of intracranial complications.

BACKGROUND There are substantial gaps in our understanding of the influence of the endoscopic endonasal approach (EEA) for endoscopic skull base surgery on sinonasal-specific quality of life (QOL) as well as the instruments available for assessment. Our primary objective in this study was to characterize postoperative changes in sinonasal QOL, specifically using the 22-item Sino-Nasal Outcome Test (SNOT-22), with a secondary objective of delineating weaknesses in our current understanding of patient symptomatology after EEA for skull base surgery. METHODS A comprehensive literature review was conducted using PubMed, CINAHL, Cochrane Library, and SCOPUS for studies reporting SNOT-22 data pre- and postoperatively in patients who underwent EEA for skull base pathologies. Studies were limited to patients ≥18 years of age and excluded patients diagnosed with chronic rhinosinusitis (CRS). RESULTS Nineteen unique studies with 27 separate data sets and a total of 1025 patients were used in this meta-analysis. Overall SNOT-22 scores statistically improved at the 6-month (p = 0.0009) and 1-year (p = 0.002) time-points. Patients with preoperative SNOT-22 scores ≥20 achieved postoperative improvements at 12-week (p < 0.00001), 6-month (p < 0.0001), 1-year (p < 0.00001), and long-term follow-up (p < 0.0001). Patients with preoperative SNOT-22 scores

Background Chronic rhinosinusitis (CRS) is a significant manifestation of cystic fibrosis (CF) with wide-ranging symptom and disease severity. The goal of the study was to determine clinical variables that correlate with outcome measures of disease severity. Methods A prospective, longitudinal, observational study of 33 adults with symptomatic CRS treated in a CF-focused otolaryngology clinic was performed. Symptom severity, the presence of rhinosinusitis exacerbations, and endoscopic appearance were assessed, and regression analysis was used to determine clinical predictors of disease outcome. Results Thirty-three adults with CF-CRS were included in the study and followed for a mean of 15 months. Rhinosinusitis exacerbations occurred in 61% of participants during the study, and female sex increased the odds of presenting with an exacerbation visit. Sinus disease exacerbations were associated with an odds ratio of 2.07 for presenting with a pulmonary exacerbation at the next visit. CF-related diabetes was found to be associated with worse symptoms and endoscopic appearance. Infection with Staphylococcus aureus predicted worsening of symptoms, whereas infections with Pseudomonas aeruginosa improved over time. Allergic rhinitis was associated with worse endoscopic appearance, and nasal steroid use was associated with improved endoscopic appearance. Conclusion Sex, CF-related diabetes, sinonasal infection status, allergic rhinitis, and nasal steroid use may all modulate severity of CF-CRS in adults. Sinusitis exacerbation may be a precursor to pulmonary exacerbation.

Background Cognitive dysfunction in chronic rhinosinusitis (CRS) is often overlooked despite potentially broad implications. Earlier work has demonstrated decreased cognitive function in CRS patients at baseline. In this study we sought to prospectively evaluate the impact of initial, appropriate medical therapy on subjective and objective cognitive function, fatigue, and workplace productivity. Methods Adult patients with CRS were prospectively enrolled and completed a robust battery of pretreatment quality-of-life and neurocognitive testing, before undergoing appropriate medical therapy with follow-up testing at 6 weeks. Patient-reported cognitive function was assessed using the Cognitive Failures Questionnaire (CFQ), whereas fatigue was measured with the Fatigue Severity Scale (FSS). Objective cognitive function was assessed using the Automated Neuropsychological Assessment Metrics (ANAM) platform and workplace productivity using the Clinical Trials version of the World Health Organization Health and Work Performance Questionnaire (ctHPQ). Results Twenty-seven patients were enrolled. Patients demonstrated posttreatment improvement scores on the FSS (4.32 ± 1.78 to 3.28 ± 1.65; p = 0.003), Pittsburgh Sleep Quality Index (8.62 ± 5.06 to 6.85 ± 4.11; p = 0.014), and CFQ (38.56 ± 16.40 to 33.04 ± 14.35; p = 0.046). Objective neurocognitive tests of mathematical processing and Stroop Reaction Test Block 3 improved after medical therapy (19.79 ± 5.61 to 21.3 ± 6.87; p = 0.029 and 43.06 ± 15.66 to 50.42 ± 19.34; p = 0.002, respectively). Measures of workplace productivity did not change significantly. Conclusion Appropriate medical therapy improves several measures of cognitive dysfunction in patients with CRS. Sustainability of results should be evaluated with larger, prolonged studies.

Background Allergic fungal rhinosinusitis (AFRS) is characterized by higher revision endoscopic sinus surgery (ESS) rates and unique radiographic features when compared to chronic rhinosinusitis with nasal polyposis (CRSwNP) or chronic rhinosinusitis without nasal polyposis (CRSsNP). Objective We hypothesized that an increased frequency of concha bullosa in AFRS or other radiographic nuances might allow for accumulation of allergic mucin and contribute to increased ESS revision rates. Methods A retrospective cohort study was performed. Patient diagnosis (AFRS, CRSwNP, and CRSsNP), basic demographics, and prior ESS rates were collected. Results A total of 210 consecutive patients were included (AFRS = 70, CRSwNP = 70, and CRSsNP = 70). Pediatric AFRS patients had more unilateral disease (38.1% vs 4.4%; P = .007) and anterior ethmoid skull base erosion (23.8% vs 6.7%; P = .047) than adult AFRS patients. AFRS patients were more likely to be younger (24.9 ± 10.1 years vs 45.6 ± 14.4 years vs 48.7 ± 18.2 years; P Conclusion In this cohort, pediatric AFRS patients had more unilateral disease and anterior ethmoid skull base erosion. Concha bullosa prevalence was significantly higher in AFRS as compared to those with CRSwNP or CRSsNP, despite prior ESS. Surgeons should consider concha bullosa as a potential anatomical subsite to harbor recurrent or residual disease.

This case-control study investigated the association between long-term exposure to particulate matter with an aerodynamic diameter of no more than 2.5 μm with anosmia., Key Points Question What is the association of long-term exposure to the air pollutant, ambient particulate matter (PM) with an aerodynamic diameter of no more than 2.5 μm (PM2.5), and anosmia, ie, the inability to smell? Findings In this case-control study that measured PM2.5 exposure levels among 2690 patients at intervals for 5 years, there was a dose-response association between PM2.5 exposure levels and anosmia that persisted despite controlling for comorbidities known to be associated with olfaction. Meaning These findings suggest that cumulative exposure to fine PM is associated with an increased risk of anosmia., Importance Anosmia, the loss of the sense of smell, has profound implications for patient safety, well-being, and quality of life, and it is a predictor of patient frailty and mortality. Exposure to air pollution may be an olfactory insult that contributes to the development of anosmia. Objective To investigate the association between long-term exposure to particulate matter (PM) with an aerodynamic diameter of no more than 2.5 μm (PM2.5) with anosmia. Design, Setting, and Participants This case-control study examined individuals who presented from January 1, 2013, through December 31, 2016, at an academic medical center in Baltimore, Maryland. Case participants were diagnosed with anosmia by board-certified otolaryngologists. Control participants were selected using the nearest neighbor matching strategy for age, sex, race/ethnicity, and date of diagnosis. Data analysis was conducted from September 2020 to March 2021. Exposures Ambient PM2.5 levels. Main Outcomes and Measures Novel method to quantify ambient PM2.5 exposure levels in patients diagnosed with anosmia compared with matched control participants. Results A total of 2690 patients were identified with a mean (SD) age of 55.3 (16.6) years. The case group included 538 patients with anosmia (20%), and the control group included 2152 matched control participants (80%). Most of the individuals in the case and control groups were women, White patients, had overweight (BMI 25 to

BACKGROUND: Viral respiratory infections are a leading cause of worldwide mortality and exert the potential to cause global socioeconomic crises. However, inexpensive, efficacious, and rapidly deployable strategies to reduce viral transmission are increasingly important in the setting of an ongoing pandemic, though not entirely understood. This article provides a comprehensive review of commonly employed nonpharmacological interventions to interrupt viral spread and provides evidence-based recommendations for their use. METHODOLOGY: A systematic review of three databases was performed. Studies with defined endpoints of subjects receiving one of five interventions (nasal washing, gargling, personal protective equipment (PPE), social distancing, and hand hygiene) were included. An evidence-based review of the highest level of evidence, with recommendations, was created in accordance with a previously described, rigorous, iterative process. RESULTS: Fifty-four primary studies were included. The most commonly studied intervention was hand hygiene, followed by PPE, gargling, saline nasal washing, and social distancing. CONCLUSIONS: Mask use and hand hygiene are strong recommendations for prevention of viral transmission. Donning gloves, gowns, and eye protection are a recommendation in healthcare settings. Saline nasal washing and gargling are options in selected populations. Although an aggregate level of evidence is not provided, the authors recommend social distancing.

BACKGROUND Sinonasal adenocarcinoma (SNAC) is a rare tumor. The impact of health disparities on survival, stage at presentation, and utilization of surgery is not well understood in patients with SNAC. METHODS The Surveillance, Epidemiology, and End Results database was queried for cases of SNAC from 1973 to 2015. Cases were analyzed to assess for disparities in presentation, treatment, and survival. RESULTS SNAC was identified in 630 patients. In a multivariate model of overall survival, an age increase of 10 years (Hazard Ratio (HR) = 1.37, p

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.

To evaluate the influence of body mass index on postoperative adverse events in adult patients undergoing endoscopic sinus surgery.Retrospective cohort study.Database of the American College of Surgeons NSQIP (National Surgical Quality Improvement Program) from 2006 to 2018.The NSQIP database was queried for adult patients undergoing endoscopic sinus surgery. The total sample (N = 1546) was stratified by nonobese (18.5 kg/mObese patients accounted for 49.7% (n = 768) of the cohort. Obese patients had a higher American Society of Anesthesiologists classification (class III, 45.1% vs 29.5%;Obesity does not increase the risk of 30-day adverse outcomes following endoscopic sinus surgery and may even be protective against perioperative bleeding.

BACKGROUND: Recent literature suggests that concurrent septoplasty during endoscopic sinus surgery (ESS) improves patient outcomes, however, the underlying indications for performing concurrent septoplasty are unknown. The objective of this study was to investigate the relationship between objective radiologic measures of nasal septal deviation with preoperative patient symptomatology and measures of CRS disease severity. We also sought to understand the association of objective radiologic measurements with surgeon performance of concurrent septoplasty during ESS. METHODOLOGY/PRINCIPAL: Seventy-four patients with CRS undergoing ESS were prospectively enrolled. Angles of septal deviation, intranasal areas and volumes were assessed on preoperative computed tomography (CT) scans and correlated with a robust battery of patient reported outcomes measures (PROMs), objective measures of CRS severity including olfaction scores, radiologic and endoscopic staging, and performance of septoplasty. RESULTS: Intranasal areas and volumes demonstrated only weak linear associations with patient-reported nasal congestion, however, angles of septal deviation alone did not correlate with congestion or any other PROM measure. Meanwhile, radiologic septal-related measurements did not correlate with objective measures of CRS disease severity or the performance of a concurrent septoplasty. CONCLUSIONS: Though prior studies demonstrate improved patient outcomes in the setting of concurrent septoplasty during ESS, this study failed to establish an association between preoperative radiologic septal-related measurements and patient symptomatology or surgeon decision to perform septoplasty. Although objective factors to identify patients most likely to benefit from concurrent septoplasty remain unidentified, the potential improvement of surgical recommendations and patient outcomes makes this an important area of continued investigation.

Frailty is known to influence cost-related surgical outcomes in neurosurgery, but quantifying frailty is often challenging. Therefore, we investigated the predictive value of the 5-factor modified frailty index (mFI-5) on total hospital charges, LOS, and 90-day readmission for patients undergoing pituitary surgery. The medical records of all patients undergoing endoscopic endonasal resection of pituitary adenomas at an academic medical center between January 2017 and December 2018 were retrospectively reviewed. Bivariate statistical analyses were conducted using Fisher’s exact test, chi-square test, and independent samples t-test. Linear and logistic regression models were used for multivariate analysis. Our cohort (n = 234) had a mean age of 53.8 years (standard deviation 14.6 years). Sex distributions were equal, and most patients were Caucasian (59%). On multivariate linear regression, with each one-point increase in mFI-5, total LOS increased by 0.64 days in the overall cohort (p

Purpose This comparative survey of surgical practice patterns between 2010 and 2020 aims to elicit trends in practice patterns for transsphenoidal surgery and to identify areas for improvement. Methods Web-based surveys were sent to the International Society of Pituitary Surgeons via a membership listserv in 2010 and 2020. These 33-item surveys collected information on demographics, surgical approach, perceived advantages and disadvantages, and recommendations for improvements. Statistical analyses were conducted using the Mann-Whitney U test for continuous variables and Fisher's exact test for categorical variables. Results There were 51 respondents in 2010 and 82 respondents in 2020. The majority were full-time academic surgeons from the United States or Europe. Preference for a purely endoscopic technique increased from 43% in 2010 to 87% in 2020. Preference for routinely working with an otolaryngologist or second neurosurgeon increased from 35 to 51%. Most surgeons (74%) reported that they were more likely to achieve a greater extent of resection with the endoscope, though 51% noted increased operating time. The most commonly rated advantage (34%) of endoscopic TSS was fewer postoperative nasoseptal perforations; the most commonly (34%) rated disadvantage was more postoperative complications, including cerebrospinal fluid leak. Respondents were divided on whether microscopic TSS should continue to be taught in residency. Many (32%) advocated for improved endoscopic instrumentation and team training. Conclusion Endoscopic TSS is now the clearly preferred method for surgery amongst a cohort of higher-volume academic neurosurgeons. This trend is likely to continue, and this provides guidelines for future training.

The ongoing outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has become a major threat to global health [1]. The mechanism of cellular entry by SARS-CoV-2 is through binding to angiotensin-converting enzyme 2 (ACE2) [2, 3], a metalloproteinase ectoenzyme that primarily functions in the regulation of angiotensin II, but also has non-catalytic roles such as intestinal neutral amino acid transport. The level of ACE2 protein and its subcellular localisation in the respiratory tract may be a key determinant of susceptibility to infection, symptoms, and outcomes in COVID-19. In humans, ACE2 protein is broadly expressed in the lung, kidney, and small intestine [4]. Pathological analysis of COVID-19 postmortem samples shows substantial damage in the lung [5], suggesting that the airway is the principal entry and target of SARS-CoV-2. However, analysis of multiple single cell RNA-seq datasets reveal overall low ACE2 RNA transcription in nasal airway epithelium, with further reduced expression in lower airway club cells and rare expression in alveolar epithelial cells [6]. This pattern of ACE2 expression provides evidence that the upper, rather than the lower, airway is the initial site of SARS-CoV-2 infection., ACE2 protein is expressed at high levels in the human olfactory epithelium relative to upper airway epithelial cells. This may explain COVID-19-associated olfactory dysfunction, while suggesting a SARS-CoV-2 reservoir site and potential intranasal therapy.

Background Olfactory dysfunction (OD) is common, affecting an estimated 13 million adults in the United States. Prior studies may underestimate OD prevalence due to use of brief smell identification tests or age-adjusted cutoff values, which concede that it is acceptable for older people to have a decreased sense of smell. Objective To determine OD prevalence in the healthy community when the goal and expectation is ideal olfactory function, rather than age-based population norms. Secondary goals were to explore factors associated with OD. Methods Subjects without otolaryngic complaints were recruited from the community surrounding the Medical University of South Carolina. Olfactory-specific information was collected, and olfactory function was assessed using the Sniffin’ Sticks test (Burghardt, Wedel, Germany) to measure threshold, discrimination, and identification (TDI). OD was defined as a TDI score Results In total, 176 subjects were included with mean age of 52 years (range: 20–93), 111 (63%) female, and 127 (72%) white. Mean TDI score was 28.8 (6.9) and OD was present in 94 (53%) subjects. Multivariate linear regression revealed that TDI decreased an average of 1 point every 5 years. TDI was also associated with Mini-Mental Status Examination (MMSE) score, asthma, and gastroesophageal reflux disease. Threshold was associated with age, heart problems, and gastroesophageal reflux disease. Discrimination was associated with age and MMSE scores. Identification was associated with age, heart problems, and anxiety. Conclusions In a community-based sample, OD affects greater than 50% of subjects. Aging impacts all aspects of olfaction, while the effects of factors such as asthma, MMSE scores, gastroesophageal reflux disease, heart problems, and anxiety may only be evident in specific olfactory subtests.

Background Post-viral olfactory dysfunction (PVOD) is one of the most common causes of olfactory loss. Despite its prevalence, optimal treatment strategies remain unclear. This article provides a comprehensive review of PVOD treatment options and provides evidence-based recommendations for their use. Methods A systematic review of the Medline, Embase, Cochrane, Web of Science, Scopus, and Google Scholar databases was completed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies with defined olfactory outcomes of patients treated for PVOD following medical, surgical, acupuncture, or olfactory training interventions were included. The Clinical Practice Guideline Development Manual and Conference on Guideline Standardization (COGS) instrument recommendations were followed in accordance with a previously described, rigorous, iterative process to create an evidence-based review with recommendations. Results From 552 initial candidate articles, 36 studies with data for 2183 patients with PVOD were ultimately included. The most common method to assess olfactory outcomes was Sniffin' Sticks. Broad treatment categories included: olfactory training, systemic steroids, topical therapies, a variety of heterogeneous non-steroidal oral medications, and acupuncture. Conclusion Based on the available evidence, olfactory training is a recommendation for the treatment of PVOD. The use of short-term systemic and/or topical steroids is an option in select patients after careful consideration of potential risks of oral steroids. Though some pharmacological investigations offer promising preliminary results for systemic and topical medications alike, a paucity of high-quality studies limits the ability to make meaningful evidence-based recommendations for the use of these therapies for the treatment of PVOD.

Introduction Silent sinus syndrome (SSS) is a condition characterized by ophthalmologic features, such as spontaneous enophthalmos and hypoglobus with ipsilateral maxillary sinus atelectasis and an otherwise asymptomatic presentation. SSS has been documented secondary to a number of external causes, including trauma or surgery, but has less commonly been described in the setting of a potential mass in the deep masticator space. Case Presentation A 56-year-old woman with a history of chronic headaches with normal prior sinonasal imaging presented with increasing right-sided facial pain and headaches that radiated to her occiput, subjective visual changes, sharp ear pain, and long-standing subjective diminished sense of smell. Physical examination was normal, while nasal endoscopy demonstrated lateral bowing of the medial maxillary wall on the right. Magnetic resonance imaging demonstrated a homogenous 2 × 2 × 2.4 cm T1- and T2-weighted, hyperintense mass lesion in the deep masticator space splaying the right medial and lateral pterygoid muscles concerning for a possible lipomatous lesion. Computed tomography revealed an atelectatic and opacified maxillary sinus with inward bowing of the posterior maxillary wall and increased orbital volume on that side. Endoscopic maxillary antrostomy was performed with biopsy of the retromaxillary space lesion and with near immediate resolution of the patient’s symptoms. Histologic examination of the mass demonstrated mature adipose tissue with few aggregates of benign small vessels. Discussion This is an unusual presentation of SSS, with an accompanying enlargement of the retromaxillary fat pad. We herein review our clinical experience with SSS and provide a literature review of the presentation, management, and perioperative considerations for SSS.

Background Despite the tremendous burden of smell and taste dysfunction in patients with chronic rhinosinusitis (CRS), objective measures of smell and taste fail to fully account for eating-related disruptions in CRS patient quality of life (QOL). In this study we sought to investigate the driving force behind impaired eating-related QOL in CRS patients. Methods Adult CRS patients were prospectively enrolled and answered a series of surveys relating to smell, taste, overall sinus-specific QOL, and depression. Patients with both smell-related and taste-related eating complaints were considered to have impaired eating-related QOL. Clinical demographics, objective chemosensory scores, and endoscopy scores were collected. Results Seventy patients were enrolled and 23% showed impaired eating-related QOL. In multivariable analyses, patients with aspirin-exacerbated respiratory disease (AERD) showed 10.7 times higher odds of impaired eating-related QOL (odds ratio [OR] 10.72; 95% confidence interval [CI], 1.09 to 105.09; p = 0.042); meanwhile, for every 1-point increase in depression scores, the odds of impaired eating-related QOL increased by 1.3 (OR 1.31; 95% CI, 1.10 to 1.57; p = 0.003). For every 1-point decrease in orthonasal olfactory threshold, the odds of impaired eating-related QOL increased by 1.9 times (OR 1.85; 95% CI, 1.14 to 3.00; p = 0.013). Symptom scores, polyp status, endoscopic scores, and other olfactory measures did not remain significant after adjusting for other variables in forward-selection multivariable modeling. Conclusion Disruptions in eating-related QOL cannot be fully explained by objective smell or taste testing alone. We identified AERD and depression as independent risk factors for greater odds of impaired eating-related QOL in CRS. Improved orthonasal threshold scores were independently associated with better eating-related QOL.

BackgroundChronic rhinitis impacts 60 million Americans and is associated with significant costs for patients. Although medical treatments are first line, some patients require surgical intervention such as vidian or posterial nasal neurectomy. Previous reviews have investigated the role of surgical management in chronic rhinitis, but none have investigated a longstanding treatment with recent interest: cryotherapy.ObjectiveTo identify the safety, efficacy, and durability of treatment response of cryotherapy in treating chronic rhinitis.MethodsA systematic literature review was performed to identify studies that investigated the utility of cryotherapy in chronic rhinitis. Only studies with the primary objective of assessing the efficacy of cryotherapy on chronic rhinitis were included. Patients were classified as allergic rhinitis, nonallergic rhinitis (vasomotor rhinitis), or mixed rhinitis using the original author’s criteria. Data were extracted regarding reported complications, treatment efficacy, and length of follow-up.ResultsA total of 110 abstracts were identified, of which 15 were included in this review. Epistaxis and nasal obstruction were commonly reported complications. No serious adverse events were reported. For obstructive symptoms, “reduced” symptoms were reported in 63.4% to 100% of patients. In regard to rhinorrhea, reports of reduced symptoms were experienced from 77% to 100% of patients. Seven studies used only patient-reported improvements without stratifying results based on symptom type; general improvements ranged from 67% to 100%. Nine studies noted symptom improvement in nonallergic cohorts ranging from 67% to 97.5% of patients. Four studies noted improvement in allergic cohorts ranging from 63.4% to 80% of patients. Two studies noted improvement in patients with mixed pictures ranging from 92.5% to 100%.ConclusionsAlthough cryotherapy appears safe and efficacious, heterogeneous past investigations with low-quality evidence make strong, evidence-based recommendations difficult to make. Further study with validated metrics and controlled populations is certainly warranted and should be encouraged.

Background Retronasal olfaction is important in flavor detection and enjoyment. The ability to identify specific individual retronasal odors may play a role in quality of life for patients with chronic rhinosinusitis (CRS). Objective To identify patterns and improve understanding of retronasal identification of individual odors in CRS patients. Methods Patients diagnosed with CRS underwent retronasal and orthonasal (Sniffin’ Sticks) olfactory testing and taste testing (taste strips). Retronasal identification was tested with presentation of flavored powders on the posterior tongue. Retronasal identification for individual odors was compared with results of orthonasal and taste testing. Results Seventy participants were evaluated. Retronasal identification correlated with orthonasal identification and discrimination for most individual odors. Among all patients, cinnamon and apple were identified better retronasally and banana better orthonasally ( P Conclusion Retronasal and orthonasal identification of most odors correlate in CRS patients; however, patients with anosmia can still identify certain retronasal odors more often than expected. These odors do not appear to stimulate gustatory pathways and may involve trigeminal stimulation. Understanding preserved retronasal neural stimuli may allow providers to improve eating-related quality of life in these patients.

Background Genetic variation of the bitter taste receptor T2R38 has been associated with recalcitrant chronic rhinosinusitis (CRS). Specific T2R38 polymorphisms, correlating with bitter taste sensitivity to phenylthiocarbamide (PTC), have been identified as an independent risk factor for surgical intervention in CRS patients without polyps; however, the exact role of PTC tasting ability in clinical practice remains unknown. In this investigation we characterize PTC taste sensitivity in a tertiary care rhinology practice with pertinent clinical measures of disease and quality of life (QOL). Methods Adult CRS patients were prospectively assessed for their ability to taste PTC and categorized as nontasters, tasters, or supertasters. Objective taste was assessed with strips for bitter, sweet, sour, and salty, whereas olfactory testing was measured with Sniffin' Sticks. Correlation was performed between PTC tasting ability and patient demographics, endoscopy scores, validated QOL surveys, and both subjective and objective measures of taste and olfaction. Results Sixty-seven patients were enrolled. Fifty-two percent were identified as nontasters, 34% as tasters, and 13% as supertasters. Nontasters were more likely to be non-Hispanic (p = 0.018), white (p = 0.027), without nasal polyposis (p = 0.004), and nonasthmatics (p = 0.019). There were no other statistical differences in patients' demographics, QOL measures, and subjective or objective olfactory and taste scores when compared with patients' oral PTC-sensing ability. Conclusion Oral PTC-sensing ability may serve as a convenient marker of increased disease severity in white CRS patients without polyps and vary among regional populations. PTC tasting ability appears to provide unique phenotypic information not obtained using other subjective or objective measures of smell and taste.

BACKGROUND Inadvertent lateralization of the middle turbinate (MT) after endoscopic sinus surgery (ESS) is cited as a common complication that results in both outflow tract obstruction and recurrent symptoms. In endoscopic endonasal skull-base surgery, the MT is frequently lateralized during the parasagittal approach. Little is known about whether this strategy has unintended consequences on the adjacent paranasal sinuses. Intentional lateralization vs surgical resection of the MT were compared for radiographic evidence of sinus obstruction in this patient population. METHODS A retrospective evaluation was conducted of pre- and postoperative Lund-MacKay (LM) scores in patients who underwent an endoscopic endonasal approach (EEA) for resection of a pituitary tumor or craniopharyngioma (transsellar or suprasellar approach) between 2012 and 2014. Side-specific LM scores were calculated at 0-3 months, 3-6 months, and >6 months. MT lateralization vs resection sides were compared. RESULTS Of the cases reviewed, 122 met the inclusion criteria. There were no statistically significant differences in LM scores of the adjacent paranasal sinuses between resected MTs as compared with surgically lateralized MTs at 3-6 months or >6 months (p = 0.551) postoperatively. Time-point of assessment was statistically significant with regard to the outcome of LM = 0 (p < 0.001), with earlier postoperative imaging correlating with higher LM scores. CONCLUSION Unlike after ESS, MT lateralization does not appear to be correlated with higher LM scores after EEA. Postoperative radiographic sinus outflow obstruction was similar in patients at all measured intervals despite differences in technical management of the MT.

OBJECTIVE The goals of this study were to assess retronasal olfaction in patients with chronic rhinosinusitis (CRS) and describe clinical factors that influence retronasal olfaction. This study sought to investigate the influence of retronasal olfaction on patient-perceived outcomes and examine the relationship between retronasal and orthonasal olfaction. METHODS Retronasal olfactory function was tested using odorized powders in the oral cavity, whereas Sniffin' Sticks test (Burghart Instruments, Wedel, Germany) were used to assess orthonasal function prospectively in 69 adult CRS patients. Endoscopic evaluation of the olfactory cleft was scored using the Olfactory Cleft Endoscopy Scale (OCES). Several quality-of-life (QOL) instruments relating to sinonasal, olfactory, and chemosensory functions were used to assess the interactions between patient-reported outcome measures and retronasal olfaction. RESULTS There was strong correlation between retronasal and total orthonasal olfaction scores (r = 0.77, P