Search

BACKGROUND Logging and landscape work are among the most hazardous occupations, and one of the most dangerous tasks in these occupations is tree felling. While much research has been conducted to examine fatalities from logging and landscape services, there is a dearth of research looking specifically at tree felling. There is a need to focus on hazards associated with tree felling activities so that proactive prevention strategies can be developed. METHODS An Occupational Safety and Health Administration (OSHA) database was used to identify occupational tree-felling fatalities in the United States during the period from 2010 through the first half of 2020. We compared data for the two industry segments of logging and landscaping services. RESULTS There were 314 fatalities over the period. The victims were overwhelmingly male with the median age being 43. Struck-by was the number one event type causing fatalities, with the head being the number one body part involved in fatalities. Falls from elevation was the only event type significantly different between the logging and landscaping industries. Poor decision-making is noted as a key component of fatal incidents, but bystanders were fatally injured due to the actions of others. CONCLUSIONS Tree felling is one of the most hazardous activities for both loggers and commercial landscapers and is a common cause of fatalities; significant differences in events and source are encountered in those two occupations. Loggers should continue efforts to adopt mechanized harvesting methods. Landscape services tree fellers should receive training related to fall prevention.

Utilizing emergency department admissions to estimate and describe agricultural injuries in the United States (U.S.) provides a unique view of one of the country's most dangerous occupations. This study characterizes and provides nationally representative estimates of persons with non-fatal agricultural-related injuries treated in emergency departments in the U.S.We conducted a cross-sectional study using U.S. Consumer Product Safety Commission, National Electronic Injury Surveillance System (NEISS) data for patients treated in emergency departments from January 1, 2015 to December 31, 2019. We queried all cases in the NEISS database using the location code "farm" and with a narrative search using relevant key words.An estimated 62,079 people were treated in an emergency department for agricultural related injuries. The mean age estimate in this population was 39 years-old, with ages ranging from 1 to 95. Almost two-thirds of patients were male, and almost 80% were white. Approximately 30% and 22% of those injured were youth and elderly patients, respectively. The majority of injuries occurred from April through September. The most common injury was fracture, followed by open wound or amputation. There were significant differences between the body parts injured in youth versus adult patients. The primary source of injury was in the vehicles category, with tractors being the dominant vehicle type.Agricultural vehicles remain a major source of injuries that require treatment in emergency departments. Previous methods of quantifying severe ag-related injuries were limited; our research utilized NEISS data to portray injury statistics more accurately.

Background Background: Pallets are key components of domestic supply chains, and yet present unique hazards when used by homeowners and retailers for unintended uses. No previous works have investigated non-occupational injuries that occur due to unintentional contact with pallets. This study sought to describe the incidence and epidemiology of non-occupational pallet-related injuries as seen in United States emergency departments (EDs). Method: The National Electronic Injury Surveillance System database was used to derive national, weighted estimates of pallet-related injuries by age, sex, injured body part, and location where injury occurred. Data for the years 2014 to 2018 were analyzed with all relevant narratives reviewed. Results: From 2014 to 2018, there were an estimated 30,493 persons who visited an ED for a pallet-related injury. The yearly incidence of pallet injuries rose during this period. The 35–44 age group (n = 5,481) was most likely to be injured, but about 3,000 children and youth under 18 years of age were injured and more than 4,000 persons 65 years of age or older suffered injuries. The elderly were especially likely to suffer injuries from slip, trip and fall incidents. The lower extremities were the most commonly injured body parts. An estimated 3,964 persons, accounting for approximately 14% of all pallet-related injuries, were treated for injuries incurred while at a retail establishment. African Americans, Hispanics, and the elderly appeared to be disproportionately more likely to have pallet-related injuries in retail locations. Conclusions: Non-occupational pallet-related injuries affect a wide range of patients and cause a variety of injuries, with the elderly being especially vulnerable to tripping incidents. Retailer prevention strategies should focus on the misuse of pallets for merchandising purposes. Industry should maintain control of pallets so they are not used for unintended purposes. Practical applications: Retailers should limit the use of pallets for floor-level merchandising purposes and remove pallets from customer-facing locations where unintentional contact could occur. Owners of pallets should maintain them in a controlled supply chain so that they don’t leak out into the hands of homeowners. Policy-makers should educate the public about the dangers of used pallets.

Objectives Pain and analgesic requirements after functional endoscopic sinus surgery (FESS) vary widely. This study aims to quantify pain after routine FESS and determine the most commonly used pain management regimen. Methods Retrospective chart review of 100 patients who underwent FESS from Oct 2017 to May 2019. Patients prospectively completed a daily pain diary and reported pain levels that were categorized into no pain (0), mild (1‐3), moderate (4‐7), or severe (8‐10). Patients were categorized into narcotics, non‐narcotics, combination, or none based on type of analgesic used. Results Sixty‐nine patients were included. Majority of patients reported either mild (39%) or no pain (28%) during the first 5 PODs. Mean POD1 pain score was 3.98, which decreased with each subsequent POD. On POD1, 37% used opioids (n = 37), 32% used non‐opioids (n = 32), 22% used a combination (n = 22), and 9% used no pain meds (n = 9). Mean number of narcotic pills used within the first 5 PODs was 2 pills on any given day. Age was inversely associated with reported POD1 pain scores (P = .003) and use of preoperative steroids in patients with sinonasal polyposis was associated with lower POD1 pain scores (P = .03). Conclusions Even on POD1, majority of patients experienced either mild or no pain, and this decreases with each POD. Narcotics are grossly overprescribed and underutilized by patients postoperatively after FESS. We advocate for more judicious prescribing habits of narcotics by Otolaryngologists after FESS, and emphasize relying on non‐narcotic alternatives like Acetaminophen or NSAIDS to diminish narcotic use and abuse in the postoperative period. Level of Evidence 4.

BACKGROUND Endoscopic transsphenoidal surgery (ETS) for the resection of pituitary adenoma has become more common throughout the past decade. Although most patients have a short postoperative hospitalization, others require a more prolonged stay. We aimed to identify predictors for prolonged hospitalization in the setting of ETS for pituitary adenomas. METHODS A retrospective chart review as performed on 658 patients undergoing ETS for pituitary adenoma at a single tertiary care academic center from 2005 to 2019. Length of stay (LoS) was defined as date of surgery to date of discharge. Patients with LoS in the top 10th percentile (prolonged LoS [PLS] >4 days, N = 72) were compared with the remainder (standard LoS [SLS], N = 586). RESULTS The average age was 54 years and 52.5% were male. The mean LoS was 2.1 days vs 7.5 days (SLS vs PLS). On univariate analysis, atrial fibrillation (p = 0.002), hypertension (p = 0.033), partial tumor resection (p < 0.001), apoplexy (p = 0.020), intraoperative cerebrospinal fluid (ioCSF) leak (p = 0.001), nasoseptal flap (p = 0.049), postoperative diabetes insipidus (DI) (p = 0.010), and readmission within 30 days (p = 0.025) were significantly associated with PLS. Preoperative continuous positive airway pressure (CPAP) (odds ratio, 15.144; 95% confidence interval, 2.596-88.346; p = 0.003) and presence of an ioCSF leak (OR, 10.362; 95% CI, 2.143-50.104; p = 0.004) remained significant on multivariable analysis. CONCLUSION For patients undergoing ETS for pituitary adenomas, an ioCSF leak or preoperative use of CPAP predicted PLS. Additional common reasons for PLS included postoperative CSF leak (10 of 72), management of DI or hypopituitarism (15 of 72), or reoperation due to surgical or medical complications (14 of 72).

Efforts aimed at minimizing the spread of COVID-19 and "flattening the curve" may be affecting clinical care delivery for non-COVID-19 cases that include otolaryngologic and orbital conditions. We are witnessing changes in the manner that patients present, as well as modifications in clinical management strategies. An improved understanding of these phenomena and the contributing factors is essential for otolaryngologists to provide sound clinical care during this unprecedented pandemic.

Background Sinonasal malignancies are a rare, heterogeneous group of tumors that often present at an advanced stage and require multimodal therapy. The presence of high-grade toxicity and sinonasal complications after treatment can negatively impact quality of life. In this study we aim to describe posttreatment morbidity in patients with sinonasal malignancy. Methods A retrospective analysis of all patients treated for sinonasal malignancy was conducted from 2005 to 2018 at a tertiary referral institution. A total of 129 patients met the inclusion criteria. Primary outcomes were treatment details, pathology, posttreatment complications, and radiation toxicity. Fisher's exact test, chi-square test, and Student t test were used for statistical analysis. Results Mean age was 58.4 (median, 61; range, 19-94) years. After diagnosis, 24 patients had surgery alone, 46 had surgery with radiation alone, 47 had surgery with chemoradiation, and 14 received definitive chemoradiation. Overall, 10.4% (n = 12) of patients had postoperative complications, and 21.0% (n = 22) had high-grade (grade 3-5) radiation toxicity. After radiation, 20% (n = 21) of patients had chronic sinusitis requiring functional endoscopic sinus surgery and 20% (n = 21) had symptomatic nasal obstruction requiring operative debridement. Conclusion Sinonasal complications, including nasal obstruction and chronic sinusitis, occur frequently after definitive treatment of sinonasal malignancy and should be addressed when considering quality of life in survivors. These complications occur more frequently in patients who undergo chemoradiation as opposed to surgery alone.

Objective A variety of endonasal sellar repair techniques have been described; many of which are complex, expensive, and carry potential morbidity but are felt to be necessary to prevent postoperative cerebrospinal fluid (CSF) leaks. We propose an effective, technically simple repair for select sellar defects utilizing an onlay of regenerated oxidized cellulose. Design Retrospective review of patients from a single neurosurgeon who underwent endoscopic transsphenoidal surgery for pituitary adenoma and sellar reconstruction with only an onlay of regenerated oxidized cellulose. Patients were selected for this repair technique based on the absence of: (1) intraoperative identification of a CSF leak, (2) patulous diaphragm (expanded diaphragm sella herniating to or through sellar floor defect), and (3) other prohibiting comorbidities. Setting The present study was conducted at a tertiary care center. Participants In this study, pituitary adenoma patients were the participants. Outcome Measures Main outcome measure of the study is postoperative CSF leak. Results A total of 172 patients were identified. Of these, 153 were initial resections of pituitary adenomas. Gross total resection was achieved in 142 (82.6%) cases. Average tumor size was 2.2 ± 1.1 cm. Average tumor volume was 10.4 ± 19.8 cm3. No patients had intraoperative CSF leaks. All cases were repaired with only an onlay of regenerated oxidized cellulose. There were two postoperative CSF leaks (1.16%). Pre and postoperative SNOT-22 scores were 12.9 ± 11.9 and 14.3 ± 14.9 (p = 0.796), respectively. Conclusion The use of an onlay of regenerated oxidized cellulose alone is an effective repair technique for select sellar defects. This technique does not result in increased postoperative CSF leak rates and avoids the higher relative cost and potential morbidity associated with more complex, multilayered closures.

Background Due to the diverse histopathologic features and variable survival rates seen in sinonasal undifferentiated carcinoma (SNUC), it is likely that this diagnostic entity is comprised of a heterogonous group of morphologically undifferentiated tumors. As advancements in molecular testing have led to a better understanding of tumor biology, it has become increasingly evident that SNUC may actually encompass several tumor subtypes with different clinical behavior. As a result, it is also likely that all SNUC patients cannot be treated in the same fashion. Recent investigations have identified loss of the tumor suppressor SMARCB1 (INI1) expression in a subset of undifferentiated sinonasal tumors and extrasinonasal tumors and, studies have suggested that this genetic aberration may be a poor prognostic marker. The objective of this study was to identify differential expression of SMARCB1 in SNUC and to analyze and compare the survival outcomes in SNUC patients with and without SMARCB1 expression. Methods All cases of undifferentiated or poorly differentiated neoplasms of the sinonasal tract treated between 2007 and 2018 at a single tertiary care institution were selected. All cases of SNUC were tested for SMARCB1 status by immunohistochemistry (IHC). Clinical parameters were analyzed using Student's t-test and Fischer's test. Kaplan–Meier methods were used to estimate survival durations, while comparison between both the subgroups was done using the log-rank test. Statistical analysis was performed with the use of SPSS software, Version 25 (IBM, New York, NY, United States). Results Fourteen cases of SNUC were identified. Approximately two-thirds (64%; n = 9) of patients were male and the majority (79%; n = 11) were between fifth to seventh decade. Skull base and orbital invasion were seen in 79% (n = 11) and 93% (n = 13) of cases, respectively. Fifty-seven percent of tumors (n = 8) retained SMARCB1 expression by IHC (SR-SNUC), while the remaining 43% (n = 6) showed loss of SMARCB1 expression and, thus, were considered as SMARCB1-deficient (SD-SNUC). Although clinicopathological features and treatment modalities were similar, SD-SNUC showed poorer (OS: p = 0.07; disease free survival [DFS]: p = 0.02) overall survival (OS) and DFS on Kaplan–Meier curves. Additionally, SD-SNUC showed higher recurrence (75 vs. 17%) and mortality (67 vs. 14%) (hazard rate = 8.562; p = 0.05) rates. Both OS (28.82 ± 31.15 vs. 53.24 ± 37.50) and DFS durations (10.62 ± 10.26 vs. 43.79 ± 40.97) were consistently worse for SD-SNUC. Five-year survival probabilities were lower for SD-SNUC (0.33 vs. 0.85). Conclusion SNUC represents a heterogeneous group of undifferentiated sinonasal malignancies. Based on the status of SMARCB1 expression, the two subgroups SD-SNUC and SR-SNUC appear to represent distinct clinical entities, with loss of SMARCB1 expression conferring an overall worse prognosis.

Anterior skull base surgery requires intimate knowledge of a highly complex anatomic region containing critical neurovascular structures. A wide array of pathologies can occur along the anterior cranial base, including meningiomas, esthesioneuroblastomas, pituitary adenomas, craniopharyngiomas, chondrosarcomas, and chordomas. Advancements in endoscopic sinus surgery have allowed many of these tumors to be effectively treated via an endoscopic endonasal technique. This approach obviates the need for large incisions causing cosmetic deformity, improves magnification of the surgical field, and offers a direct path to lesions thus avoiding retraction of structures such as the brain and nerves. Surgeons must understand the limitations of endoscopic techniques and consider open or combined open and endoscopic approaches when appropriate. Reconstructive anterior skull base techniques vary depending on the size and location of defects, along with factors such as intracranial pressure and patient co-morbidities. Large skull base defects require multilayer reconstruction that include a watertight primary dural repair with either synthetic or autologous tissue, followed by local vascularized tissue flaps. This review contains 8 figures, 2 videos, 4 tables and 33 references Key words: Anterior skull base, meningioma, esthesioneuroblastoma, chordoma, pituitary, CSF leak, nasosptal flap, dural repair, expanded endonasal approaches, endoscopic surgery

Purpose Since the COVID-19 pandemic began, emergency departments (ED) across the country have seen a significant decrease in patient visits. We aim to evaluate the impact of COVID-19 on ED visits for acute otolaryngologic complaints in New York City, one of the first epicenters of the pandemic in the US. Materials and methods We conducted a retrospective study of patients who presented to the ED with a primary diagnosis of an acute otolaryngologic complaint between March 1 and May 31 in 2019 and 2020. This was a multicenter study, including two tertiary care hospital systems encompassing Manhattan, Bronx, Queens, and Long Island. Results A total of 10,162 patients were identified. Significantly fewer patients presented to the ED for acute otolaryngologic complaints in 2020 (7332 vs 2830, p

Lesions affecting the optic apparatus vary widely with respect to their histology, location, and extent. Endoscopic endonasal approaches, including the transsphenoidal and extended transsphenoidal routes, offer excellent surgical access to the medial and inferior aspects of the optic apparatus. The extent of resection should be based on the principle of maximal safe tumor removal with preservation or restoration of visual function. Meticulous endonasal reconstruction of the cranial base defect is critical to avoid leakage of cerebrospinal fluid and infection.

BACKGROUND Although recent guidelines for obstructive sleep apnea recommend early postoperative use of continuous positive airway pressure (CPAP) after endonasal skull base surgery, the time of initiation of CPAP is unclear. In this study we used a novel, previously validated cadaveric model to analyze the pressures delivered to the cranial base and evaluate the effectiveness of various repair techniques to withstand positive pressure. METHODS Skull base defects were surgically created in 3 fresh human cadaver heads and repaired using 3 commonly used repair techniques: (1) Surgicel™ onlay; (2) dural substitute underlay with dural sealant onlay; and (3) dural substitute underlay with nasoseptal flap onlay with dural sealant. Pressure microsensors were placed in the sphenoid sinus and sella, both proximal and distal to the repair, respectively. The effectiveness of each repair technique against various CPAP pressure settings (5-20 cm H2 O) was analyzed. RESULTS Approximately 79%-95% of positive pressure administered reached the sphenoid sinus. Sellar pressure levels varied significantly across the 3 repair techniques and were lowest after the third technique. "Breach" points (CPAP settings at which sellar repair was violated) were lowest for the first group. All 3 specimens showed a breach after the first repair technique. For the second repair technique, only a single breach was created in 1 specimen at 20 cm H2 O. No breaches were created in the third group. CONCLUSION Different skull base repair techniques have varying ability to withstand CPAP. Both second and third repair techniques performed in a nearly similar fashion with regard to their ability to withstand positive pressure ventilation.

Purpose This paper aims to propose a quadruple bottom line approach for higher education leaders who must decide whether to accept sustainability initiatives that do have not have a business case. The authors describe a personal waste management program at a major university to illustrate how a quadruple bottom line framework may impact decisions to adopt a sustainability practice in higher education. The authors also demonstrate how opportunity costs can be applied to better understand the true costs of such waste management programs. Design/methodology/approach This exploratory research uses a case study approach with a unique accounting method to determine the costs of a personal waste management system. System costs are calculated for the entire university and for sample units within the university. Findings University leaders chose to continue the new waste management program in light of evidence showing higher than anticipated costs. The authors illustrate how this decision was driven by consideration of a fourth bottom line, that of the educational value of the sustainability initiative. It is discussed whether proposed sustainability initiatives such as these should be evaluated using a traditional triple bottom line framework, or, in the case of higher education, if equal consideration should also be given to factors related to the educational mission of the institution. Originality/value The authors develop a quadruple bottom line framework to explain the frequent implementation of economically costly sustainability programs in higher education contexts. This paper also reviews the rise of “personal waste management” programs at higher education institutions, demonstrates how the value of employee time can and should be considered as a cost of a comprehensive campus sustainability program (i.e. recycling and composting) and illustrates a novel means for using opportunity costs to determine those costs.

To determine the pooled global prevalence of olfactory and gustatory dysfunction in patients with the 2019 novel coronavirus (COVID-19).Literature searches of PubMed, Embase, and Scopus were conducted on April 19, 2020, to include articles written in English that reported the prevalence of olfactory or gustatory dysfunction in COVID-19 patients.Search strategies developed for each database contained keywords such asTen studies were analyzed for olfactory dysfunction (n = 1627), demonstrating 52.73% (95% CI, 29.64%-75.23%) prevalence among patients with COVID-19. Nine studies were analyzed for gustatory dysfunction (n = 1390), demonstrating 43.93% (95% CI, 20.46%-68.95%) prevalence. Subgroup analyses were conducted for studies evaluating olfactory dysfunction using nonvalidated and validated instruments and demonstrated 36.64% (95% CI, 18.31%-57.24%) and 86.60% (95% CI, 72.95%-95.95%) prevalence, respectively.Olfactory and gustatory dysfunction are common symptoms in patients with COVID-19 and may represent early symptoms in the clinical course of infection. Increased awareness of this fact may encourage earlier diagnosis and treatment, as well as heighten vigilance for viral transmission. To our knowledge, this is the first meta-analysis to report on the prevalence of these symptoms in COVID-19 patients.

To examine opioid-prescribing patterns after endocrine surgery. To evaluate factors associated with postoperative pain and opioid use.Cross-sectional.Academic university health system.The study sample included 209 patients who underwent total thyroidectomy, hemithyroidectomy, or parathyroidectomy by 4 surgeons between August 2015 and November 2017. Eighty-nine patients completed a phone survey about postoperative pain and opioid use. Prescription, demographic, and comorbidity data were collected retrospectively. Patient characteristics associated with opioid use, use of ≥10 opioid pills, and pain score were identified via chi-square, t test, analysis of variance, or Pearson correlation. Identified factors were further assessed with multivariable logistic and linear regression modeling.The median numbers of opioid pills prescribed were 20 for total thyroidectomy, 25 for hemithyroidectomy, and 20 for parathyroidectomy, and the median numbers of pills used were 1.5, 2, and 0, respectively. Of 1947 total prescribed pills, 19.7% were reported to be taken. The number of pills meeting the opioid needs of 80% of these patients was 10. In multivariable analyses, older age was associated with lower odds of opioid use (odds ratio, 0.97; 95% CI, 0.94-0.999; P = .04) and lower pain scores (Pearson correlation coefficient, -0.05; 95% CI, -0.10 to 0.001, P = .04). Charlson Comorbidity Index score5 was associated with use of ≥10 pills (odds ratio, 6.62; 95% CI, 1.60-27.50; P = .01).Excess opioids are often prescribed for endocrine surgery. By using an ideal pill number and understanding predictors of postoperative pain, surgeons can more adequately treat pain and limit excess opioid prescriptions.

BACKGROUND Bacteria, particularly in the biofilm state, may be implicated in the pathogenesis of chronic rhinosinusitis (CRS) and enhance antibiotic resistance. Nitric oxide (NO) is a gaseous immunomodulator with antimicrobial activity and a short half-life, complicating achievement of therapeutic concentrations. We hypothesized that a novel microparticle-based delivery platform, which allows for adjustable release of NO, could exhibit potent antibacterial effects. METHODS Porous organosilica microparticles (SNO-MP) containing nitrosylated thiol groups were formulated. Dissociation of the nitrosothiol groups generates NO at body temperature. The susceptibility of bacterial isolates from CRS patients to SNO-MP was evaluated through a colony forming unit (CFU) assay. Serial dilutions of SNO-MP in triplicate were incubated with isolates in suspension for 6 hours followed by plating on tryptic soy agar and overnight incubation followed by CFU quantification. Statistical analysis was performed with SPSS using one-way analysis of variance with Bonferroni correction. RESULTS SNO-MP displayed antibacterial activity against gram-positive (methicillin-resistant and -sensitive Staphylococcus aureus) and gram-negative (Pseudomonas aeruginosa, Enterobacter aerogenes, and Proteus mirabilis) isolates. SNO-MP induced dose-dependent reductions in CFU across all strains. Compared with controls and blank nanoparticles, SNO-MP (10 mg/mL) induced a 99.99%-100% reduction in CFU across all isolates, equivalent to a 5-9 log kill (p < 0.005). There was no statistically significant difference in CFU concentration between controls and blank microparticles. CONCLUSION SNO-MP demonstrates potent bactericidal effect against antibiotic-resistant CRS bacterial strains.

BACKGROUND There is a paucity of data supporting antibiotic use in endoscopic sinus surgery (ESS). The objective of this study is to determine perioperative antibiotic use patterns and factors which influence use in ESS. METHODS An online-based survey was distributed to members of the American Rhinologic Society (ARS). Outcomes included timing of perioperative antibiotic use, practice environment, years of experience, and patient factors that influenced antibiotic use. RESULTS There were 204 responses (response rate 18.3%); 36.8% of respondents were in academic positions, 32.8% were in private practice, and 30.4% were in academic-affiliated private practice; 20.6% routinely gave preoperative antibiotics, most commonly to reduce bacterial burden (59.5%) and mucosal inflammation (59.5%); 54.4% routinely gave intraoperative antibiotics, most commonly to reduce the risk of postoperative infection (63.1%); 62.3% routinely gave postoperative antibiotics, citing the need to reduce the risk of postoperative infection (75.6%). Diagnosis influenced postoperative antibiotic use in 63.0%. Preoperative antibiotics were more likely to be prescribed by respondents with more than 5 years of experience (odds ratio [OR] 2.97; 95% confidence interval [CI], 1.04 to 8.54; p = 0.043). Compared to private practitioners, academicians were more likely to give intraoperative antibiotics (OR 2.68; 95% CI, 1.39 to 5.17; p = 0.003), but not preoperative or postoperative antibiotics. Use of nonabsorbable packing was significantly associated with use of postoperative antibiotics (OR 2.01; 95% CI, 1.07 to 3.77; p = 0.031). CONCLUSION This study demonstrates the significant variation in perioperative antibiotic use among otolaryngologists. These results provide support for the establishment of evidence-based practice guidelines for perioperative antibiotic use in ESS.

BACKGROUND The endoscopic modified Lothrop procedure (EMLP) has been used as a salvage technique for frontal sinusitis following failed endoscopic sinus surgery (ESS). We aim to examine the safety and efficacy of the EMLP following failure of primary ESS. METHODS All English-language publications from 2000 to 2016 reporting the use of EMLP after primary ESS were identified using the PubMed database and evaluated per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Random effects summaries of patient demographics, comorbidities, and surgical outcomes were obtained through meta-analysis. RESULTS Eleven studies constituting 778 patients were included and 86.5% had chronic rhinosinusitis (CRS). Mean follow-up duration was 28.4 months. The mean number of surgeries prior to EMLP was 3.5. Symptom improvement was reported in 82.3%. Subgroup analysis of 7 studies in which all 357 patients had CRS revealed a mean follow-up of 31.5 months. Symptom improvement occurred in 75.9% of cases and 23.1% experienced polyp recurrence. The cerebrospinal fluid leak rate was 2.5%. Restenosis of the neo-ostium occurred in 17.1% with complete closure occurring in 3.9% of cases. The reoperation rate after EMLP was 9.0%. Aspirin sensitivity was associated with an increased risk of cerebrospinal fluid (CSF) leak (p = 0.0339) and a reduced incidence of neo-ostium closure (p = 0.0001). Aspirin sensitivity and asthma were associated with a reduced incidence of reoperation (p ≤ 0.001) and increased symptom improvement (p < 0.005). Restenosis or closure of the frontal neo-ostium was associated with less symptom improvement (p < 0.04) but not with reoperation. CONCLUSION The EMLP is an effective salvage procedure for refractory frontal sinusitis based on data from higher-volume centers.

Nasal obstruction and oral breathing may play an important role in the pathophysiology of obstructive sleep apnea (OSA). This study aims to better understand the link between oral breathing, nasal obstruction, and the spectrum of sleep-disordered breathing. Prospective study. Prospective study of patients who presented to the Otolaryngology clinic and underwent polysomnogram (PSG) from 2015 to 2016. Patients were divided into two groups based on the severity of their OSA as defined by PSG results. Both apnea-hypopnea index (AHI) and supine and REM AHI (SUP-REMe AHI), a parameter that takes into account both sleep position and sleep stage, were recorded. The primary outcome was awake nasal-oral forced expiratory volume in 1-s (FEV1) ratio as measured by handheld spirometry. A total of 21 patients were included in the study. We found that nasal-oral FEV1 ratio was significantly different between patients with minimal and substantial OSA as stratified by SUP-REMe AHI, while not significant when stratified by AHI. Patients with substantial OSA as determined by SUP-REMe AHI are more likely to have decreased awake nasal airflow as measured by nasal-oral FEV1. SUP-REMe AHI may represent an improved metric of OSA severity by taking into account sleep position and sleep stage. Handheld spirometers have the potential to become an important office tool by allowing for easy and reliable measurement of nasal airflow.

Objective Patients undergoing endoscopic endonasal surgery have historically been restricted from using straws postoperatively, due to the concern that this activity generates negative pressure. The objective of this study is to evaluate the pressure dynamics in the sinonasal cavity associated with the use of a straw. Methods Intracranial pressure catheters were placed in the nasal cavity of 20 healthy individuals. Pressure measurements were then recorded while participants drank liquids of different viscosities from a cup and from a straw. Measurements were recorded with and without subjects occluding their nose to simulate postoperative nasal obstruction. Results The average pressure in the nasal cavity while drinking water from a cup was −0.86 cmH2O, from a straw was −1.09 cmH2O, and while occluding the nose and using a straw was −0.81 cmH2O. The average pressure in the nasal cavity while drinking a milkshake from a cup was −0.98 cmH2O, from a straw was −1.88 cmH2O, and while occluding the nose and using a straw was −1.37 cmH2O. There was no statistically significant difference in pressure measurements when comparing either task or consistency (p > 0.05). Conclusion Straw use is not associated with the generation of significant negative pressure in the nasal cavity. The pressure generated when drinking from a straw is not significantly different from that of drinking from a cup. This data suggest that straw use may be safe for patients following endoscopic skull base surgery, but further investigation is warranted.

Endoscopic sinus surgery (ESS) is considered a safe and effective intervention for select pediatric sinus disorders, including both chronic and acute conditions. Surgical intervention is most commonly considered for patients with pediatric chronic rhinosinusitis who have failed medical management. Outcomes and rates of success of surgical intervention vary significantly, which can be largely attributed to a lack of consensus on indications, technique, concurrent medical therapy, and postoperative management. More investigation is necessary to build an evidence-based surgical paradigm and to identify which pediatric patients would benefit most from surgical intervention.

Background Inverted papillomas (IPs) are benign, locally aggressive neoplasms with a high recurrence rate that most commonly arise from the lateral nasal wall. Rarely, IP can originate from the lacrimal sac and/or nasolacrimal duct (NLD) system. A 58-year-old man presented with chronic epiphora and an enlarging mass inferior to his left medial canthal tendon (MCT) for 2 years. Objective The patients’ clinical presentation and surgical management are described. A literature review on IP of the lacrimal sac and NLD system was conducted. Methods Case report. Results We present a case of an IP that arose primarily from the lacrimal sac and grew below the MCT rather than extending above it. This is one of few published case reports detailing the use of a combined endoscopic and external approach for the resection of an IP of the lacrimal sac. Conclusion Combined endoscopic and external resection is a viable approach for complete removal of extensive IP of the lacrimal sac and NLD system. IP arising from the lacrimal sac may grow below the MCT or extend above it as previously reported.

Pituitary adenomas are typically slow-growing benign tumors. However, 50% to 60% of tumors progress following subtotal resection and up to 30% recur after apparent complete resection. Options for treatment of recurrent pituitary adenomas include repeat surgical resection, radiation therapy, and systemic therapies. There is no consensus approach for the management of recurrent pituitary adenomas. This article reviews the natural history of recurrent adenomas and emerging biomarkers predictive of clinical behavior as well as the outcomes associated with the various treatment modalities for these challenging tumors, with an emphasis on the surgical treatment.

While most people believe the nasal septum to have intrinsic deviation and overgrowth in patients seeking rhinoplasty, an alternative concept is that a mal-oriented premaxilla causes extrinsic septal buckling and external extrusion of the septal cartilage. In this sense, the premaxillary bone plays a significant role in the pathogenesis of septal deviation. This study was performed to determine if non-traumatically acquired septal/nasal functional and aesthetic pathology or septal deviation may be related to the orientation of the premaxilla relative to the skullbase. A retrospective, single-center study of patients in the general population who underwent maxillofacial CT scans and presented for the evaluation of nasal obstruction. CT scans were used to measure features of both pathologic and non-pathologic nasal septums. A total of 68 subjects were evaluated. When comparing patients with a premaxillary-skullbase angle of greater than 81° (the mean of the study group) to those of less than 81°, and a more obtuse nasolabial angle was observed (p = 0.0269). When comparing the extremes of premaxillary rotation, specifically, greater than 87° (mean 91.7°, SD 5.1) and less than 77° (mean 70.7°, SD 3.6), the differences were more pronounced with regard to caudal septal excess (p = 0.0451) and septal deviation in the axial plane (p = 0.0150). Septal developmental changes may involve an overly rotated or more vertically oriented premaxillary bone relative to the skull base. An understanding of the cause of septal deformity may provide insight into the design of improved treatments.

Background There remains considerable variation in the extent of sinonasal preservation during the approach for endoscopic transsphenoidal hypophysectomy (TSH). We advocate for a minimally destructive approach utilizing turbinate lateralization, small posterior septectomy, no ethmoidectomy, and preservation of nasoseptal flap (NSF) pedicles bilaterally. Due to these factors, this approach may affect the rates of postoperative rhinosinusitis. The objective of this study is to define the rates of postoperative rhinosinusitis in patients undergoing this approach. Methods Single institution, retrospective chart review of patients undergoing TSH from 2005 to 2018. Results A total of 415 patients were identified and 14% developed an episode of postoperative rhinosinusitis within 3 months. These patients were significantly more likely to have had a history of recurrent acute or chronic rhinosinusitis. Most cases were sphenoethmoidal sinusitis managed with 1 to 2 courses of antibiotics. Of patients with postoperative rhinosinusitis, most did not undergo NSF. Average follow-up was 38 months. Six patients (1.4%) underwent post-TSH functional endoscopic sinus surgery (FESS). Average time from TSH to FESS was 26.3 months. Two of these patients had a history of prior chronic rhinosinusitis without polyposis. Two patients underwent revision TSH for recurrent tumor as the primary indication for surgery at time of FESS. Twenty-two-item Sino-Nasal Outcome Test (SNOT-22) scores generally increased immediately postoperatively, but frequently decreased below preoperative level by the time of last follow-up, regardless of whether patients developed rhinosinusitis. Conclusion Sinonasal preservation during TSH is associated with a low rate of postoperative rhinosinusitis requiring FESS and excellent long-term patient reported outcomes. We continue to advocate for sinonasal preservation during pituitary surgery.

Background: There is increasing evidence that biofilms are critical to the pathophysiology of chronic infections including chronic rhinosinusitis (CRS). Until relatively recently, our understanding of biofilms was limited. Recent advances in methods for biofilm identification and molecular biology have offered new insights into the role of biofilms in CRS. With these insights, investigators have begun to investigate novel therapeutic strategies that may disrupt or eradicate biofilms in CRS. Objective: This review seeks to explore the evidence implicating biofilms in CRS, discuss potential anti-biofilm therapeutic strategies, and suggest future directions for research. Results: The existing evidence strongly supports the role of biofilms in the pathogenesis of CRS. Several anti-biofilm therapies have been investigated for use in CRS and these are at variable stages of development. Generally, these strategies: 1) neutralize biofilm microbes; 2) disperse existing biofilms; or 3) disrupt quorum sensing. Several of the most promising anti-biofilm therapeutic strategies are reviewed. Conclusions: A better understanding of biofilm function and their contribution to the CRS disease process will be pivotal to the development of novel treatments that may augment and, potentially, redefine the CRS treatment paradigm. There is tremendous potential for future research. Keywords: Sinusitis, Biofilms, Anti-bacterial agents, Quorum sensing, Surface-active agents, Active immune response, Innate immune response

BACKGROUND As the management of ventral skull-base pathology has transitioned from open to endonasal treatment, there has been an increased focus on the prevention and endoscopic endonasal management of internal carotid artery (ICA) and major vascular injury. The use of adenosine to induce transient hypotension or flow arrest has been previously described during intracranial aneurysm surgery; however, there have been no reports of the technique being used during endonasal skull-base surgery to achieve hemostasis following major vascular injury. METHODS Case report (n = 1) and literature review. RESULTS A 25-year-old female underwent attempted endoscopic endonasal resection of an advanced right-sided chondrosarcoma. During resection of the tumor, brisk arterial bleeding was encountered consistent with focal injury to the right cavernous ICA. Stable vascular hemostasis could not be achieved with tamponade. An intravenous bolus dose of adenosine was administered to induce a transient decrease in systemic blood pressure and facilitate placement of the muscle patch over the direct site of vascular injury. The patient subsequently underwent endovascular deconstruction of the right ICA. CONCLUSION This is the first reported use of adenosine to induce transient hypotension for a major vascular injury sustained during endonasal skull-base surgery. Based on well-established safety data from neurosurgical application, adenosine has the potential to be used as a safe and effective adjunctive technique in similar endonasal circumstances and may represent an additional tool in the armamentarium of the skull-base surgeon. Surgeons should consider having adenosine available when a risk of ICA injury is anticipated.

Introduction The development of portable, high resolution video displays such as video glasses allows clinicians the opportunity to offer patients an increased ability to visualize aspects of their physical examination in an ergonomic and cost-effective manner. The objective of this pilot study is to trial the use of video glasses for patients undergoing binocular microscopy as well as to better understand some of the potential benefits of the enhanced display option. Methods This study was comprised of a single treatment group. Patients seen in the otolaryngology clinic who required binocular microscopy for diagnosis and treatment were recruited. All patients wore video glasses during their otoscopic examination. An additional cohort of patients who required binocular microscopy were also recruited, but did not use the video glasses during their examination. Patients subsequently completed a 10-point Likert scale survey that assessed their comfort, anxiety, and satisfaction with the examination as well as their general understanding of their otologic condition. Results A total of 29 patients who used the video glasses were recruited, including those with normal examinations, cerumen impaction, or chronic ear disease. Based on the survey results, patients reported a high level of satisfaction and comfort during their exam with video glasses. Patients who used the video glasses did not exhibit any increased anxiety with their examination. Patients reported that video glasses improved their understanding and they expressed a desire to wear the glasses again during repeat exams. Conclusion This pilot study demonstrates that video glasses may represent a viable alternative display option in the otolaryngology clinic. The results show that the use of video glasses is associated with high patient comfort and satisfaction during binocular microscopy. Further investigation is warranted to determine the potential for this display option in other facets of patient care as well as in expanding patient understanding of disease and anatomy.

OBJECTIVE Cystic fibrosis (CF) patients commonly develop chronic rhinosinusitis (CRS). The impact of the most common cystic fibrosis transmembrane conductance regulator (CFTR) mutation, F508del, on the severity of sinonasal disease remains inconclusive. The objective of this study is to evaluate the impact of CFTR genotype functional classification on sinonasal disease severity in patients with CRS. METHODS Retrospective chart review of patients with CF who underwent endoscopic sinus surgery for chronic rhinosinusitis from 1998 to 2015. Patients were divided into high- or low-risk genotypes based on standardized CFTR gene functional classification. The primary outcome was the 22-item Sino-Nasal Outcome Test (SNOT-22) score. Secondary outcomes included endoscopic scores, extent of surgery performed, presence of polyposis, number of revision surgeries, and Lund-MacKay computed tomography scores. RESULTS Thirty-eight patients harbored a high-risk CFTR genotype, and 11 had a low-risk genotype. On bivariate analysis, there was no association between CFTR genotype risk stratification and measures of preoperative disease severity or postoperative outcomes. There were no associations between genotype risk stratification and outcome variables on multivariate linear regression, adjusted for age and gender. There were significant improvements in several SNOT-22 subdomains before and after endoscopic sinus surgery (P < 0.05), but the magnitude of improvement was not significantly different on the basis of CFTR genotype risk stratification. CONCLUSION High-risk CFTR genotypes are not associated with worse sinonasal disease severity or postoperative symptom control than low-risk CFTR genotypes after adjusting for confounding factors. LEVEL OF EVIDENCE Level 4. Laryngoscope, 1752-1758, 2018.

A 3-year-old boy presented to the ED with pain in the right ear and swelling in the postauricular area. When gentle pressure was applied to the postauricular area (shown in a video), keratin debris and purulence were expressed into the osteocartilaginous junction of the ear canal.

Objectives The treatment of pediatric airway stenosis represents a major challenge for the otolaryngologist. The aim of this study is to evaluate the use of bipolar radiofrequency plasma ablation (Coblation) in the treatment of pediatric airway stenosis. Study design Retrospective case series. Tertiary care pediatric academic medical center. Methods The medical records of 6 pediatric patients at Cohen Children's Medical Center from July 2009 to December 2015 were reviewed. All cases involved the use of radiofrequency plasma ablation to address airway stenosis. Patient presentation, surgical intervention(s), post-operative course and complications were analyzed. Results All 6 cases involved pediatric airway stenosis, including glottic stenosis (2), bilateral vocal fold immobility (2), and intratracheal lesions (2). Coblation was used to perform a range of different procedures, including removal of scar/granulation tissue, partial arytenoidectomy, and posterior cordectomy. All patients experienced good results without major complications, perioperative, or post-operative sequellae. Conclusion The results of this study suggest that radiofrequency plasma ablation may be an effective endoscopic tool for the treatment of pediatric airway stenosis. Further study and more patients are required as this technique becomes increasingly applied.

This article seeks to test whether a leader's position in the team's informal network strengthens or weakens the leader's team. Based on data collected from 231 employees working in 19 teams in a manufacturing organization, the study tested whether two different leader network centralities in teams' advice networks predicted team conflict and viability. Teams with more prestigious formal leaders (i.e., leaders whom a high proportion of subordinates sought out for advice) experienced lower levels of team conflict and had higher levels of team viability. In contrast, teams with leaders who brokered across subordinates within a team's advice network (i.e., leaders who had advice ties with subordinates who did not have advice ties with each other) reported elevated levels of team conflict and lower levels of team viability, even when controlling for the team leader's prestige. Team conflict mediated the effects of the two leader network positions on team viability.

Problem: Supervisors are increasingly important to the functioning of manuhcturing operations, in large part due to their role as leadm. While supervisors' relations and communication with their subordinates are known to be important in influencing subordinates' behavior, little is known about how these two factors will impact subordinates' safety. This study investigated how much each factor contributes to safety-related outcomes for blue-collar production employees. Method: Production employees at five Pennsylvania wood manufacturers completed a survey during their work shift. Five hundred and ninety eight employees provided data on leader-member exchange (LMX), safety communication, and safety-related events. Archival data on OSHA recordables were also obtained £kom the producers' human resources database. Results: Analyses found that the influence of LMX was greater than that of safety communication in predicting safetyrelated events. Neither LMX nor safety communication was significantly related to OSHA recordables. Results also demonstrated that employee job satisfaction and demographic variables such as gender and age have safety implications. Impact on Industry: Results from this study further emphasize the importance of production supervisors and illustrate the potential role of leader-member exchange in enhancing workplace safety. Specifically, organizations should foster positive social exchange between their employees and supervisors and enhance the leadership qualities of supervisors to help reduce workplace injuries. O 2006 National Safety Council and Elsevier Ltd. All rights reserved.

Environmental certification is playing an increasingly important role in the strategies of many businesses. This is due in large part to consumer demand for environmentally friendly products. Little is known, however, about why executives adopt environmental certification for a product or process, or how they view the benefits and challenges of certification. This paper seeks to advance our knowledge in this area by exploring executives' perceptions of benefits and challenges associated with adopting an environmental certification program. We surveyed executives in the kitchen cabinet industry about a second party certification scheme initiated for producers in that industry. Results suggest that perceptions of the benefits and challenges of environmental certification differ significantly based on whether the company had or had not adopted the certification scheme in question. The paper considers the implications for companies considering adopting environmental certification as well as for organizations providing certification schemes. Copyright © 2010 John Wiley & Sons, Ltd and ERP Environment.

Many organizations have moved to adopt high performance work designs in an effort to enhance organizational flexibility while increasing efficiency, output, and product quality. As a result, the use of voluntary organization-sponsored teams such as task forces, project teams and quality improvement teams has become increasingly common. Relatively little research, however, has examined the process through which the membership of such groups is assembled. Even less is understood about the factors that encourage greater employee participation in these types of teams. Relying on social exchange theory, social identity theory, and the diversity literature, we explore the group creation process from the individual as perspective. Specifically, we explore the factors that motivate an individual to join a particular team. Propositions relating the influence of group and relational attributes to member-initiated team selection are then developed that further expand our understanding of the effects of group attractiveness, social categorization, relational demography and network processes on group creation. In closing, we discuss the implications of our model for managers and suggest some directions for future research.