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Background: Sinonasal malignancy surveillance paradigms are often based on Head and Neck National Comprehensive Cancer Network guidelines, which do not recommend standard surveillance imaging beyond 6 months without concerning symptomatology or physical examination findings., Methods: This was a retrospective analysis of all patients who underwent resection of sinonasal malignancy at a tertiary care center over a 20-year period from 2000 to 2020, with an ensuing surveillance period demonstrating recurrence., Results: Fifty-two patients with sinonasal malignancy recurrence were included, with an average time to recurrence of 30.9 months and a follow-up period of over 60 months. Recurrence was diagnosed by routine imaging or endoscopy in asymptomatic patients in a majority (60%) of cases, while the remaining minority of diagnoses followed new symptomatology. Asymptomatic recurrence was associated with perineural spread of tumor at initial resection (p = 0.025), but not with age (p = 0.85) or stage at diagnosis (p = 0.68). Expectedly, positron emission tomography/computed tomography (CT) more often detected regional or distant recurrence, while structural imaging (CT/magnetic resonance imaging) demonstrated more frequent detection of recurrence in those with perineural spread of tumor (p = 0.01)., Conclusions: Our findings support high rates of asymptomatic recurrence in sinonasal malignancy, with the majority of recurrences diagnosed by routine endoscopy or imaging. Tailored and extended surveillance guidelines are necessary relative to those utilized for other head and neck mucosal cancers, and are especially appropriate when features such as perineural spread are present., (© 2024 The Author(s). International Forum of Allergy & Rhinology published by Wiley Periodicals LLC on behalf of American Academy of Otolaryngic Allergy and American Rhinologic Society.)

Objective: Surgical frailty estimates a patient's ability to withstand the physiologic stress of an intervention. There is limited data regarding the impact of frailty on endoscopic cerebrospinal fluid (CSF) leak repair., Methods: Patients undergoing CSF leak repair at two tertiary academic skull base programs were retrospectively reviewed. Demographic, treatment, and postoperative outcomes data were recorded. Frailty was calculated using validated indices, including the American Society of Anesthesiologists (ASA) classification, Charlson Comorbidity Index (CCI), and the Modified 5-Item Frailty Index (mFI-5). Outcomes included 30-day medical and surgical complications and readmission., Results: A total of 185 patients were included with 128 (69.2%) female patients and average age of 54 ± 14 years. The average body mass index was 34.6 ± 8.5. The most common identified etiology was idiopathic intracranial hypertension (IIH) in 64 patients (34.6%). A total of 125 patients (68%) underwent perioperative lumbar drain placement (primarily to measure intracranial pressures and diagnose IIH). Most patients were ASA class 3 (48.6%) with mean CCI 2.14 ± 2.23 and mFI-5 0.97 ± 0.90. Three patients had postoperative CSF leaks, with an overall repair success rate of 98.4%. There was no association between increased frailty and 30-day medical outcomes, surgical outcomes, or readmission (all p > 0.05)., Conclusions: Endoscopic CSF leak repair in a frail population, including lumbar drain placement and bed rest, was not associated with an increased rate of complications. Previous data suggests increased complications in open craniotomy procedures in patients with significant comorbidities. This study suggests that the endoscopic approach to CSF leak repair is well tolerated in the frail population., Level of Evidence: IV Laryngoscope, 134:2713-2717, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To characterize the patient and clinical factors that determine variability in hospital costs following endoscopic transphenoidal pituitary surgery., Methods: All endoscopic transphenoidal pituitary surgeries performed from January 1, 2015, to October 24, 2017, with complete data were evaluated in this retrospective single-institution study. The electronic medical record was reviewed for patient factors, tumor characteristics, and cost variables during each hospital stay. Multivariate linear regression was performed using Stata software., Results: The analysis included 190 patients and average length of stay was 4.71 days. Average total in-hospital cost was $28,624 (95% confidence interval $25,094-$32,155) with average total direct cost of $19,444 ($17,136-$21,752) and total indirect cost of $9181 ($7592-$10,409). On multivariate regression, post-operative cerebrospinal fluid (CSF) leak was associated with a significant increase in all cost variables, including a total cost increase of $40,981 ($15,474-$66,489, P = .002). Current smoking status was associated with an increased total cost of $20,189 ($6,638-$33,740, P = .004). Self-reported Caucasian ethnicity was associated with a significant decrease in total cost of $6646 (-$12,760 to -$532, P = .033). Post-operative DI was associated with increased costs across all variables that were not statistically significant., Conclusions: Post-operative CSF leak, current smoking status, and non-Caucasian ethnicity were associated with significantly increased costs. Understanding of cost drivers of endoscopic transphenoidal pituitary surgery is critical for future cost control and value creation initiatives., Level of Evidence: 3 Laryngoscope, 131:760-764, 2021., (© 2020 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Background: Aspirin therapy and/or type 2 (T2) biologics are used in the management of aspirin-exacerbated respiratory disease (AERD). Objective: To identify the number of patients with AERD who tolerated aspirin therapy, yet due to persistent symptoms, incorporated T2 biologic management. Methods: A retrospective review was performed between July 2016 and June 2019. Patients with AERD and who underwent endoscopic sinus surgery (ESS), aspirin desensitization (AD), and at least 6 months of aspirin therapy (ATAD) after AD, and who remained biologic-naive up through this timepoint were included in the study. Introduction of a T2 biologic while on ATAD was the primary outcome. The secondary outcome was a change in a validated patient-reported outcome measure for chronic rhinosinusitis score between the postoperative predesensitization timepoint, and the 6-month postdesensitization timepoint, presented as means and compared by using the Student's t-test. Results: A total of 103 patients met inclusion criteria. Two patients (1.9%) ultimately supplemented ATAD with a T2 biologic. The mean outcomes measure test score after 6 months of ATAD for patients who received biologics was 40.5 versus 15 in those who did not receive biologics (p = 0.02). The mean differences between the postoperative predesensitization test score and the 6-month postdesensitization test score for patients who went on to receive biologics was an increase of 13 versus a decrease of 10 for those patients who did not receive biologics (p = 0.12). Conclusion: ESS, coupled with AD and ATAD, was successful in the long-term management of the majority of the patients with AERD, which rarely required the incorporation of T2 biologics. Patient questionnaires, such as outcomes measure test score, may identify aspirin therapy failures and help guide the practitioner in deciding when to introduce T2 biologics into the patient's treatment regimen.

Background: Chronic rhinosinusitis (CRS) is a common condition that affects people of all ages and negatively impacts quality of life. The goal of this study was to identify differences in outcomes by age following endoscopic sinus surgery (ESS) for CRS utilizing 22-item Sino-Nasal Outcome Test (SNOT-22) scores., Methods: Data from 1252 adult CRS patients electing to undergo ESS (2007-2018) were collected retrospectively. The median age of 50 years was used to divide the data into 2 groups for comparison of the impact of age on SNOT-22 scores at 0, 3, and 6 months after surgery. Changes in SNOT-22 scores were analyzed using a mixed models analysis., Results: After adjusting for gender, race, polyp status, and number of prior ESSs, patients younger than 50 years had a higher mean pre-ESS SNOT-22 score (44.0) compared to those of at least 50 years of age (38.9). Among patients younger than 50 years, SNOT-22 scores declined by 20.7 points at 3 months post-ESS and 16.1 points at 6 months post-ESS. The rate of change between the dichotomized age groups was not significantly different at 3 and 6 months post-ESS (p = 0.7952 and p = 0.1057, respectively)., Conclusion: Both age groups showed significant and durable improvement in SNOT-22 scores after ESS. Patients younger than 50 years of age have higher pre-ESS SNOT-22 scores, but converge to the same SNOT-22 scores by 3 months post-ESS. The rate of change of SNOT-22 scores is not different between those younger than 50 years and those of at least 50 years., (© 2019 ARS-AAOA, LLC.)

Background: Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS)., Methods: Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus., Results: The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated., Conclusion: A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings., (© 2019 ARS-AAOA, LLC.)

Objective: Chronic rhinosinusitis (CRS) is a proposed risk factor for meningitis and other intracranial complications following the endoscopic endonasal transsphenoidal approach (TSA). Some have recommended staging TSA following surgery for CRS; however, delaying TSA has important ramifications. The objective of this study is to determine whether asymptomatic sinonasal inflammation (RSNI) on preoperative computed tomography scans, without clinical CRS, is associated with postoperative complications following TSA., Methods: All consecutive TSA cases performed at a single tertiary care institution from January 1, 2009, to December 31, 2017, were reviewed for patient demographics, prior surgery, presence of RSNI on preoperative computed tomography scan based on Lund-Mackay (LM) score, intraoperative cerebrospinal fluid (CSF) leak, and postoperative complications (postoperative CSF leak, bleeding, infection). The association between preoperative RSNI and postoperative complications was analyzed via multivariate logistic regression., Results: One hundred seventy-one cases of TSA were included with mean patient age of 52.6 years, 42.7% males, 18.1% revision cases, and mean LM score of 1.9 ± 2.7. Complications were identified in 9.9% of patients at the following rates: 5.3% postoperative CSF leak, 2.9% bleeding, and 1.8% infection (all sinusitis, no episodes of meningitis). Neither total LM score nor LM score > 5 (representative of clinically significant radiographic CRS) were predictors of any postoperative complication (both P > 0.05). Age, sex, revision status, intraoperative CSF leak, and total LM score were not independent predictors of any postoperative complication on multivariate analysis (all P > 0.05)., Conclusion: In asymptomatic patients, radiographic evidence of sinonasal inflammation is not associated with increased risk of complications following TSA., Level of Evidence: 4 Laryngoscope, 129:1545-1548, 2019., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Currently, due to the rarity of pathology, there are limited data surrounding outcomes of pediatric skull base surgery. Traditionally, surgeons have proceeded with caution when electing endonasal endoscopic transsellar/transplanum approaches to the skull base in pediatric patients due to poor sphenoid pneumatization. In this study, we review outcomes of endoscopic pediatric skull base surgery based on sphenoid pneumatization patterns., Study Design: Retrospective chart review., Methods: A review of all cases of pediatric (age < 18 years) craniopharyngioma managed via an endoscopic endonasal approach at a tertiary academic medical center., Results: A total of 27 patients were included in the analysis. The median age was 8 years. Nineteen (70%) patients were male. Presellar, sellar/postsellar, and conchal sphenoid pneumatizations were found in 6, 11, and 10 patients, respectively. There was no significant association between sphenoid pneumatization pattern and extent of resection (gross vs. subtotal, P = .414), postoperative cerebrospinal fluid (CSF) leak (P = .450), intraoperative estimated blood loss (P = .098), total operative time (P = .540), and length of stay (P = .336). On multivariate analysis, after accounting for age, sex, preoperative cranial nerve involvement, and cavernous sinus invasion, there remained no significant association between sphenoid pneumatization pattern and extent of resection (P = .999) and postoperative CSF leak (P = .959)., Conclusions: Sphenoid pneumatization pattern does not appear to affect outcomes in endoscopic skull base surgery in the pediatric population. Importantly, lack of sphenoid pneumatization does not impede gross total resection or increase complications. Thorough knowledge of the anatomy during the endoscopic approach is critical to optimize outcomes., Level of Evidence: 4 Laryngoscope, 129:832-836, 2019., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To survey patients following sinonasal surgery regarding postoperative pain and opioid use., Study Design: Patients were surveyed for 4 days following sinus and/or nasal surgery regarding their pain level and use of prescribed opioids., Setting: Four academic medical centers and 1 private practice institution., Subjects: Consecutive adult patients undergoing sinonasal surgery., Results: A total of 219 subjects met criteria and were included for analysis; 134 patients (61%) took 5 or fewer combination oxycodone (5-mg) and acetaminophen (325-mg) tablets in the first 3 postoperative days, and 196 patients (89.5%) took fewer than 15. Fifty-one patients (23%) consumed no opioid pain medication. Opioid consumption was positively correlated with postoperative pain ( R 2 = 0.2, P < .01) but was not correlated with the use of acetaminophen ( R 2 = 0.002, P = .48). No significant difference in postoperative pain or opioid consumption was seen with respect to age, sex, specific procedures performed, postoperative steroids, or smoking history. Current smokers reported higher average pain than nonsmokers ( P < .001) and also required more postoperative opioids ( P = .02)., Conclusions: An evidence-based approach to postoperative pain control following sinonasal surgery that reduces the number of unused and potentially diverted opioids is needed. The current study suggests that 15 combination oxycodone (5-mg) and acetaminophen (325-mg) tablets provide sufficient pain control for 90% of patients in the immediate postoperative period following sinonasal surgery, irrespective of the specific procedures performed, use of acetaminophen, or use of systemic steroids. Smoking status may help surgeons predict which patients will require larger opioid prescriptions.

Purpose of Review: Lesions of the petrous apex of the temporal bone can be challenging to access and approaches laterally through the mastoid as well as medially through an endonasal approach are utilized to access this region while preserving function of adjacent structures. Cholesterol granulomas of the petrous apex requiring surgery are marsupialized to prevent expansion of the inflamed cyst and relieve associated clinical symptoms. The endonasal approach to the petrous apex has in the past been limited to lesions medial to the internal carotid artery., Recent Findings: Endoscopic approaches have been developed to expand the range of petrous apex lesions that are accessible endonasally. These endonasal corridors include a nasopharyngeal/transclival corridor, lateralization of the internal carotid artery to create an expanded medial window, a pterygopalatine infrapetrosal approach, and a contralateral maxillary approach, which allow improved access to the inferior and lateral petrous apex. Nasoseptal flaps may reduce the risk of postoperative stenosis of the drainage tract., Summary: Endoscopic endonasal approaches can be used safely to address both medial and lateral/inferior petrous apex lesions. Morbidity of these procedures is low and use of a nasoseptal flap may limit restenosis of the drainage pathway.

Objectives: Improvement in sinonasal quality of life (QoL) following sinus surgery has been well-documented across the literature. To our knowledge, only one series has evaluated long-term QoL in patients undergoing tumor resection, and that study demonstrated no improvement in rhinologic QoL following malignant tumor resection at 2-year follow-up. The objective of the present study was to evaluate QoL in the 2 years following endoscopic malignant tumor resection., Methods: A prospective cohort study was performed, including patients with both malignant and benign sinonasal tumors in a tertiary academic medical center. Patients undergoing endoscopic tumor resection who had completed Sinonasal Outcome Test 22 (SNOT-22) questionnaires were included in the cohort. SNOT-22 questionnaires were administered preoperatively and over a 2-year follow-up period at clinic visits. Longitudinal linear mixed-effects regression was used to compare preoperative QoL to QoL over the 2 years following surgery., Results: Among 145 patients included in this study, 64 had malignant tumors. There was a statistically significant improvement in SNOT-22 score from baseline to 2 years for patients with both malignant tumors (37.0, 95% confidence Interval [CI] 32.0-42.1 at baseline; 26.5 95% CI 20.8-32.2 at 2 years; P < 0.001) and benign tumors (26.5, 95% CI 21.4-30.4 at baseline; 12.9 95% CI 7.6-18.2 at 2 years; P < 0.001)., Conclusion: In contrast to previously reported series, in this cohort endoscopic resection of sinonasal tumors appears to be followed by an improvement in QoL, which is sustained over a 2-year period., Level of Evidence: 2b. Laryngoscope, 128:789-793, 2018., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: In this study we assessed patient outcomes after complete endoscopic sinus surgery (ESS) and aspirin desensitization for patients with aspirin-exacerbated respiratory disease (AERD)., Methods: A retrospective chart review was conducted for patients with aspirin challenge-proven AERD who underwent complete ESS followed by aspirin desensitization. Outcomes assessed included need for revision surgery and quality-of-life measures using the 22-item Sino-Nasal Outcomes Test (SNOT-22). Data were collected preoperatively, postoperatively prior to desensitization, and then at intervals post-desensitization through 30 months after aspirin desensitization. A longitudinal linear mixed-effects model was used for data analysis., Results: Thirty-four patients met the inclusion criteria for this study. Thirty-two patients successfully completed aspirin desensitization and were subsequently followed for 30 months after desensitization. Two patients were unable to complete desensitization. Five patients discontinued aspirin maintenance therapy due to gastrointestinal and respiratory side effects. Within the follow-up period, there were only 3 (9.4%) revision sinus surgeries. Notably, 1 of these revision cases occurred in a patient who had discontinued aspirin maintenance therapy. After surgical treatment and prior to desensitization patients had significant reductions in SNOT-22 scores. Our results demonstrate that total SNOT-22 scores remained statistically unchanged from immediate post-desensitization throughout the 30-month follow-up period., Conclusion: Complete sinus surgery followed by timely aspirin desensitization and maintenance therapy is an effective combination in the long-term management of sinus disease in patients with AERD., (© 2017 ARS-AAOA, LLC.)

Background: Advanced-stage olfactory neuroblastoma requires multimodal therapy for optimal outcomes. Debate exists over endoscopic endonasal surgery in this situation. Stage-matched open and endoscopic surgical therapy were compared., Methods: Patients from 6 cancer institutions were assessed. Stratification included dural involvement, Kadish stage, nodal disease, Hyams' grade, approach, and margin status. At follow-up, local control, nodal status, and evidence of distant metastases were recorded with any subsequent therapy. Statistical analyses to identify risk factors for developing recurrence and survival differences were performed., Results: One hundred nine patients were assessed (age 49.2 ± 13.0 years; 46% women) representing Kadish A stage (10%), Kadish B stage (25%), and Kadish C stage (65%). The majority of the patients (61.5%) underwent endoscopic resection, 53.5% within Kadish C stage. Within-stage survival analysis favored endoscopic subgroup for Kadish C stage (log-rank P = .017) nonsignificant for Kadish B stage (log-rank P = .39)., Conclusion: Stage-matched survival was better for the endoscopically treated group compared to the open surgery group, with high negative margin resections obtained., (© 2017 Wiley Periodicals, Inc.)

Background: Few studies have established surgical landmarks for endoscopic endonasal dissection of the intraconal orbital apex (OA)., Objective: We describe the optic nerve (ON) anatomy and its relationships, as seen during a fully endoscopic, endonasal approach to the medial intraconal OA., Methods: The study question was approached through a cadaver dissection and a radiographic study. Four formalin-fixed, latex-injected cadaver heads were dissected using transnasal endoscopic techniques. Dissection was performed using 0 degree and 30 degree nasal endoscopes and standard endoscopic sinus surgical instrumentation. A bi-nostril 4-handed technique was used. The anatomy of 8 medial OAs was evaluated and recorded. As the radiographic portion, 100 consecutively enrolled patient magnetic resonance images were evaluated, with particular attention given to the relationship of the ON to the medial rectus muscle (MRM) in 200 orbits., Results: Intraconally, the ON consistently coursed along the superior half of the MRM. Interestingly, the nerve was more easily identified from a superior approach after retracting the MRM inferiorly. With the identification of the nerve at the OA, carrying the dissection of the medial OA was easily accomplished with the ON as the guiding landmark. The radiographic portion of this study revealed a consistent relationship between the superior edge of the ON and the MRM. This relationship was maintained in the orbital apex in 98.4%-100% of the orbits examined., Conclusion: The superior edge of the optic nerve is consistently found coursing along the superior half of the MRM, facilitating facile identification and further dissection navigation., (Copyright © 2016 by the Congress of Neurological Surgeons)

Management of anterior skull base defects is an area of continued innovation for skull base surgeons. Various grafting materials have been advocated for the repair of skull base defects depending on needs, availability, harvest site morbidity, and surgeon preference. Spontaneous bony closure of small skull defects is known to occur in animal models without bone grafts, but this phenomenon has been unexplored in the human skull base. The objective of this study was to evaluate osseous skull base closure in patients undergoing endoscopic repair of skull base defects. A retrospective review was performed on 13 patients who underwent endoscopic repair of skull base defects with free bone grafts who were followed with postoperative computed tomography scans. This cohort was compared to postoperative radiology from patients undergoing transsphenoidal surgery without rigid reconstruction to evaluate for spontaneous osseous closure of sellar defects. Free bone grafts are incorporated into the bony skull base in the majority of patients (84.6% with at least partial incorporation) at mean of 5.3 years postoperatively. By comparison, patients undergoing pituitary surgery did not demonstrate spontaneous osseous closure on postoperative imaging. Human anterior skull base defects do not appear to spontaneously close, even when small, suggesting that there is no "critical size defect" in the human skull base, in contrast to the robust wound healing in animal models of skull convexity and mandibular defects. Free bone grafts incorporate into the skull base over the long-term and may be utilized whenever a rigid skull base reconstruction is desired, regardless of the defect size.

Background: The purpose of this study was to assess the utility of imaging and endoscopy in posttreatment surveillance of sinonasal malignancies., Methods: We conducted a retrospective analysis of primary sinonasal malignancies diagnosed between 2000 and 2014. Posttreatment surveillance included nasal endoscopy and imaging (MRI, CT, and positron emission tomography [PET]/CT). Positive predictive value (PPV), negative predictive value (NPV), specificity, and sensitivity were calculated for each modality and compared., Results: One hundred nine sinonasal malignancies were identified with 30 recurrences. Endoscopy showed a sensitivity and specificity of 24% and 89%, respectively, whereas imaging was 76% and 90%, respectively. Identifying suspicious symptoms significantly improved the PPV of both endoscopy and imaging. MRI demonstrates the highest PPV when compared with other imaging modalities., Conclusion: Both modalities are necessary in posttreatment surveillance. MRI shows the highest PPV, whereas endoscopy trends toward a higher specificity. PET/CT scans have a high false-positive rate and should be reserved for tumors with a high propensity for distant metastases. © 2016 Wiley Periodicals, Inc. Head Neck 38:1229-1233, 2016., (© 2016 Wiley Periodicals, Inc.)

Objectives/hypothesis: Malignant sinonasal and skull base tumors are now being resected using an endoscopic technique, but there has been controversy regarding the oncologic safety of this approach. Various studies have compared the outcomes from endoscopic surgery to those from open techniques; however, all have been limited by substantial differences in the patient populations receiving each approach. In this study we compare outcomes of open and endoscopic techniques and use propensity score matching to control for these differences in the patient populations., Study Design: Retrospective cohort study including all patients > 18 years old receiving primary surgery for malignant sinonasal or skull base tumors at our institution from 2002 to 2013., Results: One hundred twenty-four patients met criteria; 82 received endoscopic-only surgery, and 42 had an open component to their approach. There was an 86% 3-year overall survival and a 74% disease-free survival. Without controlling for differences in the groups, the endoscopic patients fared significantly better in survival, recurrence rates, wound infections, and length of hospital stay. When using propensity score matching to account for patient comorbidities and tumor size, there were no significant differences in any outcomes except length of the hospital stay. A multivariate regression analysis yielded the same results., Conclusion: In this study, endoscopic surgery was shown to be a safe alternative to the open technique, even when controlling for the favorable patient and tumor characteristics in endoscopic patients. This is the first study to account for these differences with a rigorous statistical methodology., Level of Evidence: 4. Laryngoscope, 126:1724-1729, 2016., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Introduction: Cerebrospinal fluid (CSF) leak occurs in 1-11% of endoscopic Draf III, or endoscopic modified Lothrop, procedures. CSF leak can occur during surgery during a superior nasal septectomy. This study investigated whether the posterior edge of the nasofrontal beak (NFB) at the level of the internal frontal ostium is a safe landmark to use to avoid skull base injury when beginning the superior septectomy., Methods: Preoperative computed tomography maxillofacial scans were reviewed from 100 patients from the University of Pennsylvania sinus surgery data base. The narrowest anteroposterior distance between the posterior edge of the NFB and the anterior aspect of the olfactory fossa (OF) at the level of the internal frontal ostium was measured in each patient. Measurements were taken in the midline and to the left and right of midline. Six fresh cadaver heads were also dissected to evaluate these relationships., Results: On computed tomography analysis, the NFB was anterior to the OF on the left and right of the midline in 100% of the patients, with mean distances of 6.04 and 6.41 mm, respectively. The NFB was anterior to the OF in the midline in 98% of patients, with a mean distance of 9.02 mm. In all six cadavers, the posterior edge of the NFB was anterior to the OF in the midline and to the left and right of midline at the level of the internal frontal ostia., Conclusions: During Draf III, the posterior edge of the NFB was a reliable landmark for avoiding iatrogenic CSF leak during the superior septectomy.

Objectives/hypothesis: Topical sinus irrigations play a critical role in the management of sinonasal disease, and the improvement in irrigant penetration into the sinuses postoperatively greatly contributes to the success of endoscopic sinus surgery. Prior investigations on postoperative sinus irrigations have been mostly limited to cadaver studies, which are labor intensive and do not capture the full dynamics of the flows. A pilot study was conducted to investigate the impact of surgery on sinus irrigation through computational fluid dynamics (CFD) simulations., Study Design: Retrospective computational study., Methods: Pre- and postoperative computed tomography (CT) scans were obtained on a patient who underwent standard endoscopic surgeries for all sinuses, including a Draf III frontal sinusotomy. CT-based pre- and postoperative CFD models then simulated irrigations of 120 mL saline per nostril at 12 mL/s (typical of Sinugator) and 60 mL/s (SinusRinse Bottle), in two head positions: face parallel and at a 45° angle to the ground., Results: Overall, surgery most significantly improved frontal sinus irrigation, but surprisingly resulted in less maxillary and ethmoid sinuses penetration. This may due to the partial removal of the septum during the Draf III, causing most fluid to exit prematurely across the resected septum. Higher flow rate slightly improved ethmoid sinus irrigation, but resulted in less preoperative contralateral maxillary sinus penetration., Conclusions: CFD modeling of sinonasal irrigations is a novel technique for evaluating irrigant penetration of individual sinus cavities. It may prove useful in determining the optimal degree of surgery or the ideal irrigation strategy to allow for maximal and targeted sinus irrigant penetration., Level of Evidence: NA Laryngoscope, 126:E90-E96, 2016., Competing Interests: No conflict of interest and no financial disclosure., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Surgical treatment of inverted papilloma (IP) of the sphenoid sinus is complicated by close proximity to vital structures of the skull base. Identifying the site of tumor attachment and achieving complete removal can be challenging compared to IP at other sites. The objective of this study is to illustrate the clinical presentation, management, and risk factors for tumor recurrence for sphenoid IP., Study Design: Retrospective study., Methods: A multi-institutional, retrospective review of endoscopic resections of IP based within the sphenoid sinus was performed from 1996 to 2014. Demographic and tumor data, operative notes, complications, and recurrence rates were collected. Statistical analysis was performed to identify risk factors for tumor recurrence., Results: Forty-eight patients (31 males, 17 females) were identified. Mean age was 57 years, with a median follow-up of 13.6 months (range 6.8-36). Rate of tumor recurrence was 14.6%, with median time to recurrence of 13.1 months. Patients with dysplasia/carcinoma in situ (CIS) had a 3.6 greater rate of recurrence (RR) compared to patients with no dysplasia, approaching significance (RR = 3.6; P = 0.08). Patients with IP attachment sites overlying the optic nerve or carotid artery had a 4.76 greater rate of recurrence compared to other sites (RR = 4.76; P = 0.073)., Conclusion: Sphenoid sinus IP is associated with a 14.6% rate of recurrence after surgery. Potential risk factors for tumor recurrence identified in this study include attachment sites over the optic nerve and carotid artery or evidence of dysplasia or CIS. Close follow-up in the postoperative period is essential for these patients to monitor for tumor recurrence., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Purpose of Review: To review the current literature on the expanded endonasal approach for pediatric skull base lesions., Recent Findings: This review examines the currently published outcomes of pediatric endoscopic skull base surgery. It specifically reviews the anatomic considerations of pediatric patients, growth considerations in pediatric patients, reconstructive options and limitations, and the use of image guidance. In addition, this review provides some suggestions for approaching skull base lesions in pediatric patients, based on both experience and the current body of literature., Summary: The expanded endonasal approach for pediatric skull base lesions is a well tolerated and reliable method for the treatment of children with midline nasal masses. With improvements in technology and technique, this approach has become increasingly common in high-volume skull base centers as a well tolerated alternative to traditional open approaches.

Background: Despite their widespread use, antibiotics have not been shown to improve chronic rhinosinusitis (CRS) outcomes. We aimed to determine whether culture-inappropriate postoperative antibiotic therapy was associated with less quality-of-life (QOL) improvement following functional endoscopic sinus surgery (FESS)., Methods: This retrospective cohort study recruited 376 adult CRS patients undergoing FESS between October 1, 2007 to December 31, 2011. Patient demographics, comorbidities and medications were collected at baseline. Trimethoprim-sulfamethoxazole and clindamycin were administered for 2 weeks postoperatively. The antibiotic appropriateness was determined based on bacterial resistance profile of organisms identified during intraoperative culture. The QOL outcome was defined as change of 22-item Sinonasal Outcome Test scores from preoperative visit to 1-month, 3-month, and 6-month post-FESS. Clinically significant difference was defined as at least 0.5 standard deviations (SD) of baseline QOL score in the reference group. Mixed-effects regression models were performed., Results: Seven percent of patients (n = 27) had culture-inappropriate antibiotic therapy, and additional 5% (n = 19) had culture-specific antibiotic adjustment. Compared to patients with culture-appropriate antibiotics, patients with culture-inappropriate antibiotics had significantly less improvement of QOL from baseline to postoperative 1-month and 3-month follow-up where the difference became clinically significant; patients with antibiotic adjustment had more QOL improvement from baseline to 1-month follow-up, but their QOL worsened at 3-month follow-up, and these changes were not clinically significant. However, all effects washed out at 6-month follow-up with no significant differences., Conclusion: Culture-inappropriate postoperative antibiotic therapy decreased short-term QOL improvement to a clinically meaningful level after FESS. Culture guided selection of antibiotics may improve short-term FESS outcome., (© 2014 ARS-AAOA, LLC.)

Background: Spontaneous cerebrospinal fluid (CSF) leaks/encephaloceles are proven to be associated with intracranial hypertension by objective measurements of CSF pressure during or following endoscopic repair. A common area of involvement is a pneumatized lateral recess of the sphenoid (LRS) sinus, where prolonged intracranial pressures lead to arachnoid pits and subsequent development of skull-base defects. Even though the LRS is never present at birth, a "congenital" cause of these leaks due to a persistent Sternberg's (lateral craniopharyngeal) canal continues to be erroneously perpetuated in the literature. The objective of this study was to eliminate the myths defining these leaks as congenital in nature., Methods: Evaluation of LRS CSF leaks present within a multiinstitutional case series was performed. Data regarding demographics, body mass index (BMI), radiologic evaluation of intracranial hypertension, and direct intracranial pressure measurements (when available) were collected., Results: Data evaluation identified 77 LRS CSF leaks in 59 patients (mean age 52 years). Obesity was present in 83% of individuals (mean BMI 36) and 81% were females. Radiologic evidence of intracranial hypertension (eg, empty sella, dilated optic nerve sheaths, and scalloped/attenuated bone) was present on 96% of preoperative computed tomography (CT) and/or magnetic resonance imaging (MRI) scans. Opening or postsurgical lumbar drain or ventriculostomy pressure measurements were elevated in 95% of patients (mean 27.7; range, 9-50 cmH2 O)., Conclusion: This study provides objective evidence that LRS CSF leaks are secondary to erosions from intracranial hypertension and refutes the myth regarding a congenital origin from Sternberg's canal., (© 2014 ARS-AAOA, LLC.)

Introduction: Postoperative CSF leak is the most common complication of endoscopic endonasal approach (EEA) to skull base lesions. Endoscopic multilayer closure of skull base defect using pedicled nasoseptal flaps (NSF) based off the sphenopalatine artery reduces CSF leaks. EEA robustly expands in surgical arena, yet postoperative imaging evaluation remains poorly studied. This work illustrates normal MR imaging appearance of skull base reconstruction utilizing NSFs during immediate postoperative period., Methods: We retrospectively identified patients who had skull base reconstructions utilizing NSFs following EEAs and immediate postoperative-enhanced brain MRI. NSFs and free grafts were evaluated for signal intensity, thickness, configuration, enhancement, vascular pedicle of NSF, relationship in multilayer reconstruction, and defect coverage. Imaging findings were correlated with surgical technique and CSF leaks., Results: Twenty-eight patients had 26 multilayer reconstructions and 34 NSFs. Twenty-nine NSFs showed enhancing C-shaped arc at the skull base. Of those, 26 flaps (90%) were confidently identified by visualization of their vascular pedicles, 3 were not distinguishable from adjacent mucosa and pedicles were not identified. Five NSFs showed no enhancement (1 CSF leak). Twenty-seven enhancing NSFs approximated defects with close abutment to free grafts. One flap was displaced; one incompletely covered the defect (2 CSF leaks). Fisher exact test demonstrated an association between incomplete defect coverage and displacement of NSFs with CSF leak (P=0.05)., Conclusion: Endoscopic skull base reconstruction utilizing NSF has characteristic MR imaging appearance. Non-enhancing mucosal gap or displacement of NSF may indicate incomplete defect coverage, identifying patients at risk for CSF leak., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Transsphenoidal and extended transsphenoidal approaches have provided improved surgical access to numerous intradural and extradural tumors from the retrosellar area to the craniovertebral junction. The evolution in reconstruction of planum, tubercular and clival skull base defects has progressed from the use of free tissue grafts alone to the use of free tissue grafts in combination with vascularized flaps. Sellar floor reconstruction is usually necessary only if intraoperative CSF leaks, prolapse of the suprasellar cistern, or bleeding from the medial aspect of the cavernous sinus occur. In patients with intraoperative CSF leak, accurate packing of the sella in the area of the arachnoid membrane tear, with or without packing of the sphenoid sinus, is performed. An increasing armamentarium of local and regional tissue flaps have reduced postoperative CSF leak rates to less than 5%. Future refinements in skull base reconstruction techniques will allow better management of patients at high risk for a postoperative CSF leak, especially those who have been previously irradiated and/or require revision surgery., (Copyright © 2013 S. Karger AG, Basel.)

Objectives: Malignant tumors of the paranasal sinuses are traditionally approached by a variety of external incisions. Recent advances in endoscopic endonasal surgery have allowed for some of these tumors to be treated endoscopically. The purpose of this study was to assess the outcomes and complications of the endoscopic approach in a series of patients with paranasal sinus malignancies., Methods: A retrospective chart review was performed of patients with sinonasal or skull base malignancies treated with endoscopic or endoscopic-assisted resections at a tertiary care institution from 2002 to 2010. Patient data were collected on symptoms, tumor type, operative technique, and postoperative course. Baseline risk factors, overall and disease-free survival data, and surgical outcomes were compared between the two groups., Results: Of the total 49 patients, 36 (73%) underwent an endoscopic approach and 13 (27%) underwent endoscopic-assisted approaches. Sarcomas (9 cases) were the most common tumor type, followed by squamous cell carcinoma (8), adenocarcinoma (8), and melanoma (7). The mean follow-up time for all patients was 3.58 years (range, 1.1 to 8.8 years). Surgical complications were more frequent with open approaches than with endoscopic approaches (23.1% versus 5.6%; p = 0.11). Medical complications were significantly more common with open approaches (38.5% versus 8.3%; p = 0.02). The disease-specific mortality rate was 8% (4 of 49). The local tumor recurrence rate was 16% (8 of 49). The 3-year disease-free survival rates were 86.8% in the endoscopic group and 67.7% in the open group (p = 0.047); however, the patients in the endoscopic group had lower T stages (p = 0.0068) and lower ASA scores (p = 0.03)., Conclusions: Endoscopic approaches to the sinuses and skull base have become progressively more sophisticated with advances in skull base reconstruction, advances in surgical technique, and improvements in technology. This study demonstrates the relative safety and utility of the endoscopic approach for sinonasal and skull base malignancies. In carefully selected patients, endoscopic approaches demonstrate survival rates comparable to those of traditional surgery, and fewer perioperative complications. With appropriate planning and careful surgical decision-making, endoscopic surgery shows promise as a minimally invasive alternative in the treatment of sinonasal malignancies.

Objectives/hypothesis: Cerebrospinal fluid (CSF) leaks continue to be the most common postoperative complication in expanded endonasal skull base procedures. Currently, a multilayer closure using a vascularized nasoseptal flap is most commonly performed for large ventral skull base defects in an effort to avoid postoperative CSF leaks. We correlated nasoseptal flap enhancement with postoperative CSF leak rates in a group of skull base reconstruction patients. The nasoseptal flap enhancement was determined by immediate postoperative gadolinium-enhanced magnetic resonance imaging (MRI), which allowed for imaging of the flap's vascular pedicle. Our aim was to identify whether nasoseptal flap enhancement contributed to reduction of postoperative CSF leak rates., Study Design: Retrospective cohort study., Methods: We reviewed 19 patients who underwent expanded endoscopic resections of skull base lesions of advanced complexity. We calculated the incidence of CSF leaks and measured the presence of nasoseptal flap enhancement., Results: Of the 19 patients with immediate postoperative MRIs, three developed postoperative CSF leaks. All three CSF leaks were in cases with enhancing vascular pedicles. In contrast, we had three patients without evidence of flap enhancement, none of whom developed a postoperative CSF leak (Fisher exact test, P = 1.0). CSF leak was associated with posterior fossa lesions (P = .25). Nasoseptal flap enhancement was associated with younger age (P = .15)., Conclusions: This retrospective cohort study demonstrates that although the vascularized pedicled nasoseptal flap is effective for closure of expanded endonasal skull base procedures, our experience found the actual enhancement of the flap itself does not appear to effect postoperative CSF leak rates., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

Background: Minimally invasive surgery for neoplasms of the anterior skull base has revolutionized the treatment of these diseases. The relative effect of endoscopic procedures, however, has not been described in terms of disease-specific and global health-related quality of life (QoL)., Methods: A single-center longitudinal study was performed of patients undergoing complete endoscopic resection of anterior skull base neoplasms. Patients presenting between October 2009 and September 2010 were enrolled. QoL assessments were based on the 22-question Sinonasal Outcomes Test (SNOT-22), Health Utilities Index Mark II (HUI-2), and Short-Form 12 (SF-12) and were completed preoperatively and at 3, 6, and 12 months postoperatively. Comparisons over time were made within subjects., Results: Fourteen patients were enrolled; 11 completed preoperative and postoperative assessments (79%). Our cohort consisted of five men and six women; mean age was 55 years. Six patients had malignant tumors; four required adjuvant therapy. SNOT-22 scores were stable or improved in 10 cases (91%), with a significant difference for the cohort (mean, -33 points; p < 0.01). Ten (91%) patients had stable or improved HUI-2 scores (mean utility change, +0.13). SF-12 scores were stable for both mental (p = 0.17) and physical (p = 0.26) components. Mean quality-adjusted life year gain over the study period was 0.07., Conclusion: Complete endoscopic resection of anterior skull base neoplasms is oncologically sound with anecdotal QoL improvements relative to open craniofacial resection. We show positive, quantifiable QoL results with validated global and disease-specific instruments. Additional work will help to improve outcomes in this population and will be used in formal cost-effectiveness analysis.

Background/aims: Tuberculum sellae meningiomas (TSMs) are challenging tumors for surgical resection. Endoscopic endonasal (EE) approaches to these lesions have not been directly compared to open craniotomy in a controlled trial., Methods: We searched Medline and Embase online databases for English-language articles containing key words related to TSMs. Data were pooled, including 5 of our own patients reported here for the first time. Metaregression was used and a decision-analytical model was constructed to compare outcomes between open microsurgery and EE approaches., Results: The overall quality of life (QOL) was not significantly different between the approaches (p = 0.410); however, there were large differences in individual complication rates. The Monte Carlo simulation yielded an overall average QOL in craniotomy patients of 0.915 and in endoscopic patients of 0.952. Endoscopy had a higher CSF leak rate (26.8 vs. 3.5%, p < 0.001) but a lower rate of injury to the optic apparatus (1.4 vs. 9.2%, p < 0.001) compared with craniotomy. The 3-year recurrence rates were not statistically different (p = 0.529)., Conclusion: EE resection of TSMs appears to be a comparable alternative to traditional open microsurgical resection with respect to overall QOL based on available publications. A meaningful comparison of recurrence rates will require a longer follow-up., (Copyright © 2012 S. Karger AG, Basel.)

Meningiomas are slow-growing benign tumors believed to originate from arachnoidal cap cells. This article discusses the surgical approaches for resection, especially the transnasal endoscopic approach. Alternative treatment options are primarily used where patients are not surgical candidates or location of recurrence precludes additional surgery. These options include radiotherapy, stereotactic radiosurgery, and chemotherapy. In addition, we discuss the current on going research in molecular targeting agents for meningioma treatment., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Lumbar drains (LD) are frequently employed with the goal of postoperative cerebrospinal fluid (CSF) leak prevention. LD placement is not without risk, however, and complications can significantly increase patient discomfort and resource utilization. The objective of this work was to characterize the risks, benefits, and resource utilization associated with LD use in endoscopic anterior skull-base surgery., Methods: A retrospective review of endoscopic anterior skull-base surgeries performed by the senior authors over the past 5 years was done. Cases with prospective LD were selected using anesthesia and billing records. Analysis was done of indications, LD duration, complications, revisions, and additional care required., Results: A total of 65 patients had LD placed prospectively at the time of surgery. LD were in place for an average of 63 ± 38 hours. Four cases (6.2%) required revision surgery for postoperative CSF leak. Leak rates did not differ between patients with neoplasm (7.7%) and without neoplasm (5.8%; p = 0.80). One readmission was attributable to a recurrent leak. Nine LD complications occurred in 8 patients (12.3%). Overall, 6 blood patches, 3 head computed tomography (CT) scans, 1 open removal of retained catheter fragments, 1 spine CT, and an infectious disease workup were required. Three readmissions and 10 additional hospital days were attributable to LD complications. No relationship was found between patient demographics or comorbidities and LD complications. Regression analysis showed no significant effect of body mass index (odds ratio [OR], 1.01; 95% confidence interval [CI], 0.89-1.14; p = 0.87) or duration of LD (OR, 1.00; 95% CI, 0.98-1.02; p = 0.85) on complication risk. Diagnosis of neoplasm was associated with a significant increase in likelihood of complication (OR, 5.33; 95% CI, 1.11-25.64; p < 0.04)., Conclusion: Complications of LD may be more frequent than postoperative CSF leaks, adding significantly to health care resource utilization. It is difficult to predict which patients will suffer LD complications. Reduction of prospective LD use may avoid unnecessary morbidity and resource utilization., (Copyright © 2011 American Rhinologic Society-American Academy of Otolaryngic Allergy, LLC.)

Background: Transnasal approaches to the anterolateral maxillary sinus and infratemporal fossa are challenging with traditional endoscopic techniques and instrumentation. Additional access in the anterior and lateral direction can be obtained with modified endoscopic medial maxillectomy (MEMM) or total endoscopic medial maxillectomy (TEMM) or via a transseptal approach. Alternatively, we have used a septal dislocation technique to help access these areas. Access to these areas may be necessary for treatment of inverted papilloma, schwannoma, and juvenile nasopharyngeal angiofibromas. The aim of this study is to examine the effectiveness of septal dislocation for anterolateral reach in extended endoscopic sinus surgery., Methods: Cadaver dissection was performed on eight sides. MEMM, TEMM, and septal dislocation were sequentially performed according to standard techniques. Image-guided axial screenshots were used to identify the extent of anterolateral reach in each stage by measuring the angle of access from the midline., Results: TEMM adds 12° of anterolateral reach when compared with MEMM. With septal dislocation, an average of 20 additional degrees is provided over TEMM. The anterior maxillary sinus is routinely accessed with straight instruments after septal dislocation., Conclusion: The anterolateral maxillary sinus and infratemporal fossa are difficult areas to access with standard endoscopic techniques. Septal dislocation is a straightforward technique to achieve additional visualization and access when combined with TEMM.

Objectives: Access to the medial orbit traditionally has been gained transcutaneously, with potential for associated soft tissue and lacrimal disruption. Endoscopic transnasal approaches to the medial orbit may be limited in certain scenarios by tumor presence or patient-specific factors. The medial transconjunctival approach, or transcaruncular approach, has been recently described for access to the medial orbit in orbital decompression and repair of medial blowout fractures. The aim of this study is to determine the utility of this minimally invasive external approach in the endoscopic management of advanced sino-orbital disease., Methods: This is a cadaver study with additional clinical correlations. The transcaruncular approach was combined with a transnasal endoscopic approach in cadaver dissections performed on eight sides. Five cases are described in which the transcaruncular approach was used as an adjunctive technique in advanced endoscopic sinus surgery., Results: In cadaver dissection, the transcaruncular approach is a simple, reliable method to ligate the ethmoid arteries and place bony cuts along the medial orbital wall. In certain anatomic configurations, supraorbital dissection into the frontal sinus or anterior fossa may be achieved. In the cases examined, exposure of the medial orbital subperiosteal plane allowed for ligation of ethmoid arteries, assessment of periorbital invasion of disease, assistance in tumor dissection, and placement of a malleable retractor for protection of orbital contents., Conclusions: The transcaruncular approach to the medial orbit has certain advantages over the traditional open approach. Ligation of the ethmoid arteries, assessment of the lacrimal sac and periorbita for tumor invasion, protection of orbital contents, and en bloc resection of the periorbita and lamina papyrecea are possible through this route.

Purpose of Review: To review and highlight recent articles on the osteoplastic flap over the last 12 months., Recent Findings: Although advances in endoscopic sinus surgery have permitted rhinologists to manage a wide range of frontal sinus disease, recent retrospective studies have examined specific indications for the osteoplastic flap in this endoscopic era. Whether it will be inflammatory, anatomical or sinonasal tumor considerations, the osteoplastic flap remains an important surgical technique when endoscopic approaches are limited., Summary: The osteoplastic flap will remain an important tool in the armamentarium of the endoscopic surgeon to provide comprehensive management of the frontal sinus.

Orbital hematoma is an uncommon but serious complication of sinus surgery. Appropriate perioperative attention may minimize risk, but early diagnosis and appropriate management are crucial to preventing vision loss. The surgeon, postoperative care staff, and patient must be aware of the signs and symptoms. Immediate examination must be performed, including pupil size, symmetry, and reactivity, visual acuity, and measurement of intraocular pressure. Immediate consultation from an ophthalmologist or oculoplastic surgeon is mandatory if the diagnosis is suspected. The surgeon and ophthalmologist should follow an algorithm of advancing therapies based on serial examination, ranging from observation only to immediate surgical intervention.

Background: The delivery of topical intranasal corticosteroid sprays has traditionally been the primary method of treating recurrent nasal polyposis. An emerging treatment for polyposis is budesonide nasal irrigations. Delivered at concentrations nearly 100 times greater than found in prescription nasal sprays, there have been little studies on the effects of budesonide irrigation on the adrenal axis. Therefore, we investigated whether irrigation with budesonide solution was associated with any increase in serum cortisol and 24-hour urinary cortisol levels., Methods: Patients who previously had undergone endoscopic sinus surgery and were not taking prednisone for 3 months were prospectively enrolled in this study. Patients irrigated twice daily with 0.5 mg/2 mL of budesonide mixed with 240 mL of saline solution. Serum cortisol and 24-hour urinary cortisol were collected before drug administration and 6 weeks after continuous use., Results: Ten patients completed this study. The average serum cortisol and 24-hour urinary cortisol before drug administration were 9.8 +/- 5.4 microg/dL and 28.1 +/- 15.1 microg/24 hours, respectively. After 6-week follow-up, the average serum cortisol and 24-hour urinary cortisol were 12.8 +/- 3.5 microg/dL and 16.5 +/- 5.6 microg/24 hours, respectively. Normal ranges for serum cortisol and 24-hour urinary cortisol are 5-25 microg/dL and 4-50 microg/24 hours, respectively., Conclusions: Irrigation with budesonide, 0.5 mg/2 mL, in 250 mL of saline solution does not result in decreases of serum cortisol and 24-hour urinary cortisol levels. Based on this, we feel irrigation with budesonide solution is safe to perform in patients as an alternative to traditional aerosolized steroid sprays or systemic corticosteroids.

As the scope of transnasal cranial-base surgery expands, reconstruction of the complex residual defects remains a challenge. Laser welding is a novel technology that can be performed endoscopically and offers the potential of producing instantaneous, watertight repairs using a chromophore-doped biologic solder.

Background: Sinonasal irrigation after endoscopic sinus surgery (ESS) is a common practice, but the role irrigation bottles play in iatrogenic contamination of the operated sinuses is unknown. Therefore, we investigated whether irrigation bottles used postoperatively become contaminated and have any potential association with immediate postsurgical infection and outcomes., Methods: Patients irrigated twice daily after ESS. Bottle cleaning was performed as recommended by the manufacturer. New bottles were distributed at the time of the operation and at each postoperative visit. During postoperative weeks 1, 2, and 4, bottles were cultured. Medical charts were reviewed for the presence of postsurgical infection and changes in management., Results: Twenty post-ESS patients were enrolled and examined at weeks 1, 2, and 4. A total of 51 bottles were collected and cultured. Overall, 15 of 51 (29%) bottles demonstrated bacterial growth when cultured. During the first two collection periods, 10 of 40 (25%) bottles demonstrated bacterial growth when cultured; however, five of 11 (45%) bottles collected at the last postoperative visit demonstrated bacterial growth when cultured. During the study, Pseudomonas aeruginosa, Acinetobacter baumannii, and Klebsiella pneumoniae were frequently recovered during the collection periods. Other organisms isolated included Escherichia coli and Enterobacter spp. Although positive bottle cultures were more common at weeks 2 and 4, no postoperative infections occurred., Conclusions: Irrigation bottles used postoperatively have a measurable incidence of contamination. Contamination rate increases when bottles are used for longer than 1 week, but this does not appear to result in postsurgical infection.

Objective: Endoscopic repair of cerebrospinal fluid (CSF) leaks has become a routine approach. This study describes endoscopic closure of a large series over 21 years, focusing on management, surgical technique, and long-term outcomes., Study Design: Chart review., Subjects and Methods: CSF leak patients treated by the senior author and at the University of Pennsylvania from 1987 to 2008. The data included body mass index (BMI), etiology, defect location, graft material, presence of encephalocele, lumbar drain, history of meningitis, intracranial pressure, recurrence, and follow-up., Results: A total of 193 cases were identified. Follow-up ranging from 1 month to 9 years (mean 21 months) was available on 166 patients. The etiology was spontaneous in 77 patients (40%), traumatic in 109 (56%), and congenital in 7 (4%). The average BMI of spontaneous CSF leak patients (35) was greater (P < 0.001) than both traumatic (30) and congenital patients (23). Defects were most commonly located in the sphenoid (n = 62, 32%) and ethmoid (n = 60, 31%) The initial success rate was 91 percent (n = 176) and overall success rate was 98 percent (n = 190)., Conclusion: The overall success rate (98%) and low morbidity in this large series support endoscopic approach as standard of care for CSF leak closure.

Purpose of Review: Cerebrospinal fluid leaks that occur spontaneously are challenging to manage clinically owing to frequent recurrences following attempted surgical closure. Understanding of the underlying pathophysiology has increased in recent years as we now recognize that the vast majority of these patients demonstrate clinical symptoms and radiographic signs of elevated intracranial pressure. Individuals with this disorder also arise from a distinct demographic group. Increased knowledge of the characteristics of this patient population along with updated medical and surgical management will provide increased success rates in the management of this clinical entity., Recent Findings: Current literature indicates that control of intracranial hyptertension, coupled with endoscopic repair, will improve success rates comparable with other etiologies. Recent information on the underlying pathophysiology of spontaneous cerebrospinal fluid leaks is discussed. Improvement in preoperative identification of radiographic signs of intracranial hypertension (i.e. empty sella), operative technique, and postoperative management of elevated intracranial pressure are also reviewed., Summary: We highlight the demographic characteristics, clinical presentation, radiologic findings, and clinical management of patients with this disorder.

Objective: To examine the clinical and anatomical characteristics of patients with supraorbital ethmoid (SOE) cerebrospinal fluid (CSF) leaks and encephaloceles and identify specific considerations unique to their management., Methods: Retrospective review of patients who underwent repair of SOE CSF leaks at our institution from 2003 to 2007., Results: The majority of patients were women (5/8), middle-aged (mean: 54.9 years) and had a high body mass index (mean 42.3). Intracranial pressures (ICPs) were elevated in 6/8 patients. Anatomically, 6/8 patients had defects medial to the medial orbital wall (MOW; mean distance: 4.15 mm) and 2/8 had defects lateral to the MOW (mean distance: 8.14 mm). Seven out of 8 were successfully repaired endoscopically, and 1 patient with a lateral defect required an adjunctive trephination., Conclusions: Patients with spontaneous SOE CSF leaks have unique clinical characteristics that include obesity and elevated ICP. Extension of a skull base defect lateral to the MOW and a narrow anterior-posterior diameter of the frontal recess are technical obstacles to endoscopic repair and may necessitate an adjunctive external approach., (Copyright 2009 S. Karger AG, Basel.)

Objective: To test the feasibility of laser tissue welding (LTW) in creating an endoscopic transluminal repair of esophageal perforation., Study Design: Animal model., Subjects and Methods: A diode laser was used to create an endoluminal rabbit esophageal perforation repair. Burst pressures were compared with open incision, external suture, and external laser-augmented suture closure. Comparisons were performed five times and analyzed with Kruskal-Wallis analysis of variance and a post hoc Dunn method., Results: The burst threshold of the endoluminal weld (54.78 +/- 5.84 mm Hg) was significantly higher than that of the open incision (6.5 +/- 1.94 mm Hg) and not significantly different than that of the external suture (37.18 +/- 1.97 mm Hg) or the laser-augmented suture group (71.60 +/- 7.58 mm Hg)., Conclusion: Laser welding is a feasible method of creating endoluminal repairs with burst strengths comparable with external suture repair, which may allow a subset of patients to avoid traditional open approaches. This is the first reported animal model of LTW for endoscopic closure of iatrogenic esophageal perforation.

Objective: To describe the endoscopic management of frontal sinus mucoeceles with anterior table erosion. Previous hardware exposure and subsequent contour defects were also assessed., Design: Retrospective case series., Methods: Thirty-seven patients (mean 48 yrs, range 20-78) with frontal sinus mucoeceles and anterior table erosion, endoscopically managed in a tertiary care setting, were reviewed. The demographic data, defect size, surgical technique, presence of exposed hardware, outcomes, and clinical follow-up were collected for outcome assessment, Results: The average follow-up was 32.6 months (range, 6-73). The overall long-term success rate with our initial endoscopic approach was 92% (34/37). The average size of anterior table defects was 181 mm2 (4-1155). Twelve patients had prior osteoplastic flaps (OPF) with obliteration and 57% (21/37) had previous endoscopic sinus surgeries. Ten patients with prior OPF operations had hardware exposed within the sinus from previous surgeries. Two patients eventually required an OPF with fat obliteration. Most defects were either unnoticeable or cosmetically acceptable to the patients. Only one patient required a contouring plate six months after the procedure. Ninety percent of patients were successfully managed with exposed hardware left in situ., Conclusions: Endoscopic marsupialization of frontal sinus mucoeceles with anterior table erosion has a high success rate with a good cosmetic outcome, often without routine reconstruction. Revision cases and those with exposed hardware did not prevent successful management.

Among the several risks encountered in endoscopic sinus surgery, catastrophic orbital bleeding and iatrogenic cerebrospinal fluid leak are the two serious complications surgeons most fear. This article discusses these avoidable complications and provides treatment algorithms for intraoperative maneuvers. A thorough understanding of the anatomy of the paranasal sinuses and their relationships with the anterior skull base, appropriate preoperative planning, and meticulous surgical technique are essential for preventing intraoperative cerebrospinal fluid leaks. Intraoperative orbital hematoma is discussed and a stepwise approach to reduce complications is provided.

Tension pneumocephalus is a rare complication of functional endoscopic sinus surgery that may lead to rapid neurologic deterioration. Patients typically display symptoms within hours after the operation, and computed tomography reveals the presence of a skull base defect. We report a unique case of subacute tension pneumocephalus with no obvious skull base defect, which was associated with a pupil-involving third-nerve palsy. We discuss management of this complication and preventive measures for avoiding pneumocephalus after functional endoscopic sinus surgery.

Background: Symptoms of postnasal drainage and thickened mucus are commonly seen in patients with chronic rhinosinusitis (CRS) recalcitrant to sinus surgery and conventional medical therapies. Chemical surfactants can act as a mucolytic by reducing water surface tension and have the potential to serve as an antimicrobial agent. Baby shampoo is an inexpensive, commercially available solution containing multiple chemical surfactants. This is an in vitro study of its antimicrobial effects on Pseudomonas biofilms with translation to a clinical study for use as an adjuvant nasal wash in patients with CRS who remain symptomatic despite adequate sinus surgery and conventional medical therapies., Methods: In vitro testing was performed to determine the optimal concentration of baby shampoo that disrupted preformed bacterial biofilms and inhibited biofilm formation. This concentration was then used in a prospective study of symptomatic post-functional endoscopic sinus surgery (FESS) patients who irrigated twice a day for 4 weeks. Validated outcome forms and objective smell testing was performed before and after therapy., Results: One percent baby shampoo in normal saline was the optimal concentration for inhibition of Pseudomonas biofilm formation. Baby shampoo had no effect on the eradication of preformed Pseudomonas biofilms. Eighteen patients with CRS with an average of 2.8 surgeries were studied after irrigating with 1% baby shampoo solution. Two patients discontinued use because of minor nasal and skin irritations; 46.6% of patients experienced an overall improvement in their subjective symptoms, and 60% of patients noted improvement in specific symptoms of thickened mucus and postnasal drainage., Conclusion: Baby shampoo nasal irrigation has promise as an inexpensive, tolerable adjuvant to conventional medical therapies for symptomatic patients after FESS. Its greatest benefit may be in improving symptoms of thickened nasal discharge and postnasal drainage.