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Hippocrates, a Greek physician during the fifth century BC., is often considered the father of medicine. The Corpus Hippocraticum comprising of 58 volumes was writing between 450 and 150 BC. The objective of our study was to detail the management of nasal polyps during this period. We read and analyzed all volumes of the Corpus Hippocraticum in French translation and extracted all passages dealing with nasal polyps (n = 6). Surgical procedures in the Corpus Hippocraticum are described in great detail. The first surgical strategy for the removal of nasal polyps was by mini-invasive nasal approach: the lopping method and the sponge method. We explain the two mini-invasive nasal approaches with drawings. The meticulously detailed observations of the corpus give us a precious insight into the early perception of diseases, their progression and early attempts of treatment.

To evaluate the time for recovery of the sense of smell in patients with CRSwNP who underwent Reboot surgery compared to patients undergoing ESS in a long-term follow-up study.Data were collected retrospectively from 168 patients with severe uncontrolled CRSwNP, who underwent revision surgery, either as Extended Endoscopic Sinus Surgery (Reboot, 140 patients) or as regular Endoscopic Sinus Surgery (ESS, 28 patients) between January 1, 2014, and December 31, 2015, aiming to compare the outcome of surgeries after 2 years of follow-up. Sense of smell was scored as judged by the patient using scores 0 to 3 reflecting a percentage estimate of remaining smell.Smell improved similarly in the Reboot and ESS groups over the first 9 months, which was maintained over 24 months in the Reboot, but not the ESS group (p = 0.007 after 18 months, p = 0.001 after 24 months). Furthermore, polyp recurrence rates were significantly lower in the Reboot group.Reboot surgery significantly improved olfactory function and significantly reduced nasal polyp recurrence rates over 2 years post-operatively. Therefore, Reboot should be considered for patients with uncontrolled severe CRSwNP, specifically when ESS failed, to offer long-term smell and a polyp-free status.3b.

Background Excessive collapse of the soft palate and lateral pharyngeal wall narrowing are established causes of loud snoring and sleep apnea in subjects with obstructive sleep apnea (OSA). Therefore, delicate surgical techniques are needed to reshape the soft palate and create sufficient tension in the lateral pharyngeal wall. This study aimed to determine the therapeutic outcome and favorable indications of soft-palate webbing flap pharyngoplasty in subjects with OSA and primary snoring. Methods A total of 174 subjects who underwent soft-palate webbing flap pharyngoplasty combined with uvulopalatal flap and septoturbinoplasty from August 2015 to February 2020 were included in this study. Medical records, including pre- and postoperative sleep parameters, were retrospectively reviewed. The primary outcome measure was the degree of improvement in AHI after surgery. Other outcomes were differences in surgical response rates, subjective visual analog score (VAS) for snoring, sleep quality, and complications. Results Polysomnographic results showed that apnea–hypopnea index (AHI) scores were significantly reduced from 39.6 ± 6.1 to 22.9 ± 3.6 following soft-palate webbing flap pharyngoplasty in 59 subjects, and overall success and response rates of this technique were analyzed with 71%. We found that the successful outcomes were observed in 50% of mild (n = 12) and 56% of moderate (n = 16) subjects with OSA subjects due to lateral pharyngeal wall collapse. The success rate of soft-palate webbing flap pharyngoplasty was relatively higher in subjects with mild and moderate OSA than those with severe OSA. Additionally, the mean VAS snoring scale was 4.7 and subjects’ primary snoring intensity significantly improved to 2.9 after soft-palate webbing flap pharyngoplasty. Subjective symptoms such as daytime sleepiness and sleep quality also showed improvement. Most complications were found to be minimal and improved by 1 month after the operation. Conclusion Our data demonstrate that soft-palate webbing flap pharyngoplasty is an effective treatment for OSA and primary snoring and may be a promising technique to reduce lateral pharyngeal wall collapse.

BackgroundNeonatal nasal obstruction may result in respiratory distress, feeding difficulties, sleep apnoea and failure to thrive; hence, it requires thorough evaluation and prompt intervention. Congenital inferior turbinate hypertrophy is relatively uncommon, and its presentation can mimic other congenital nasal anomalies.RelevanceThis paper reports two cases of congenital inferior turbinate hypertrophy in neonates that resulted in significant respiratory distress, feeding difficulties and sleep disturbance. Both patients were successfully treated surgically by endoscopic nasal dilatation and stenting. A literature search was performed to identify articles on congenital inferior turbinate hypertrophy in neonates and its management.ConclusionAlbeit rare, congenital inferior turbinate hypertrophy should be considered a differential diagnosis in newborns presenting with respiratory distress at birth.

Background Nasal obstruction is a common problem, with significant impact on quality of life. Accurate diagnosis may be challenging because of the complex and dynamic nature of the involved anatomy. Computational fluid dynamics modeling has the ability to identify specific anatomical defects, allowing for a targeted surgical approach. The goal of the current study is to better understand nasal obstruction as it pertains to disease-specific quality of life by way of a novel computational fluid dynamics model of nasal airflow. Methods Fifty-three patients with nasal obstruction underwent computational fluid dynamics modeling based on computed tomographic imaging. Nasal resistance was compared to demographic data and baseline subjective nasal patency based on Nasal Obstructive Symptom Evaluation scores. Results Mean Nasal Obstructive Symptom Evaluation score among all patients was 72.6. Nasal Obstructive Symptom Evaluation score demonstrated a significant association with nasal resistance in patients with static obstruction (p = 0.03). There was a positive correlation between Nasal Obstructive Symptom Evaluation score and nasal resistance in patients with static bilateral nasal obstruction (R2 = 0.32) and poor correlation in patients with dynamic bilateral obstruction caused by nasal valve collapse (R2 = 0.02). Patients with moderate and severe bilateral symptoms had significantly higher nasal resistance compared to those with unilateral symptoms (p = 0.048). Conclusions Nasal obstruction is a multifactorial condition in most patients. This study shows correlation between simulated nasal resistance and Nasal Obstructive Symptom Evaluation score in a select group of patients. There is currently no standardized diagnostic algorithm or gold standard objective measure of nasal airflow; however, computational fluid dynamics may better inform treatment planning and surgical techniques on an individual basis. Clinical question/level of evidence Risk, V.

To systematically review the literature to evaluate the indications, safety, and efficacy of the Draf IIb procedure and to evaluate the added advantages of technical factors such as stents and flaps.Articles published until July 2019 on Medline and Cochrane databases.After a systematic review based on the 2018 PRISMA guidelines was conducted, 26 of 1533 articles were included and reviewed for indications of Draf IIb; surgical technique; use of flaps, stents, grafts, or mitomycin; complications during and after surgery; and success or recurrence rate.The main indication for Draf IIb was chronic frontal rhinosinusitis (61.82%). The postoperative patency rate was 87.85%. When flaps/grafts were applied, the rate was 93.5%, but their added value was not statistically significant. Stents could be an alternative for revision surgery. Treating frontal pathologies other than chronic rhinosinusitis was also satisfying. Safety was comparable to Draf III: no perioperative complications were reported, only a few postoperative ones (eyelid ecchymosis and periorbital cellulitis in 0.2% of the cases, hyposmia in 1.55%).When properly indicated, Draf IIb frontal drilling is a safe and highly effective surgical technique for frontal pathology treatment, with efficiency and safety comparable to the Draf III, making it a valid option when a bilateral approach is not needed. More studies are required to confirm the added values of flaps, grafts, and stents.

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.

The application of 3D printing in planning endoscopic endonasal transsphenoidal surgery is illustrated based on the analysis of patients with intracranial skull base diseases who received treatment in our department. Cranial computed tomography/magnetic resonance imaging data are attained preoperatively, and three-dimensional reconstruction is performed using MIMICS (Materialise, Leuven, Belgium). Models of intracranial skull base diseases are printed using a 3D printer before surgery. The models clearly demonstrate the morphologies of the intracranial skull base diseases and the spatial relationship with adjacent large vessels and bones. The printing time of each model is 12.52–15.32 h, and the cost ranges from 900 to 1500 RMB. The operative approach was planned in vitro, and patients recovered postoperatively well without severe complications or death. In a questionnaire about the application of 3D printing, experienced neurosurgeons achieved scores of 7.8–8.8 out of 10, while unexperienced neurosurgeons achieved scores of 9.2–9.8. Resection of intracranial skull base lesions is demonstrated to be well assisted by 3D printing technique, which has great potential in disclosing adjacent anatomical relationships and providing the required help to clinical doctors in preoperative planning.

Objectives The aim of this prospective study was to evaluate the effect of modified extracorporeal endonasal septoplasty on nasal tip shape and function in patients with severe caudal septal deviation. Methods The study population comprised of 55 patients undergoing modified extracorporeal endonasal septoplasty, which called marionette septoplasty. To analyse the aesthetic objective outcomes, postoperative photographs were measured for projection index (PI), tip projection (TP), nasolabial angle (NLA), tip deviation angle (TDA), nasofrontal angle (NFA), supratip height (STH), columellar height (CH), at three times (2 weeks, 3, and 6 months after surgery) and were compared with preoperative photographs. Functional and aesthetic outcomes were also evaluated using nasal obstruction symptom evaluation (NOSE) scale and standardized cosmesis and health nasal outcomes survey (SCHNOS). Results Between the pre- and post-operative 6th-month examinations, a significant increase in PI and TP were 7%, and 5% respectively. There was a significant alteration in the NLA and TDA values following the last examination (mean difference ± standard error of mean 9.68 ± 0.9° and 1.5 ± 0.8°, respectively). Moreover, the technique did not make a significant change in the final NFA, STH, and CH, measurements. Following surgery, the NOSE and SCHNOS scores were decreased significantly and the improvement continued over time until the last examination. Conclusion The present study findings suggest that the marionette septoplasty technique is an effective to correct and stabilize severe caudal septal deviations. This technique also can provide tip support and protection with a low incidence of dorsal irregularity.

Performing a nasopharyngectomy via a transoral approach has been reported; however, defining landmarks to facilitate this approach has not been addressed. This study aims to explore anatomical landmarks to aid in performing a nasopharyngectomy via the transoral corridor.An endoscopic transoral nasopharyngectomy was performed on six cadaveric specimens (12 sides). Related anatomical landmarks were defined, and the strategy to preserve the parapharyngeal internal carotid artery (pICA) was explored.An endoscopic transoral nasopharyngectomy was successfully achieved in all 12 sides. Utilizing the pterygoid hamulus as a landmark, the cartilaginous ET and attachments could be adequately exposed. Identification of the pICA is a prerequisite prior to Eustachian tube (ET) transection. The sphenoidal spine and the petrotympanic fissure could be sufficiently revealed in all 12 sides, which aided in transection of the cartilaginous ET without pICA injury. The ET and the prevertebral contents could be adequately removed via the transoral corridor.The pterygoid hamulus, sphenoidal spine and petrotympanic fissure serve as reliable landmarks for performing a transoral nasopharyngectomy. Identification of the pICA is a prerequisite prior to transection of the ET to avoid pICA injury.

The emergence of steerable flexible instruments has widened the uptake of minimally invasive surgical techniques. In sinus surgery, such flexible instruments could enable the access to difficult-to-reach anatomical areas. However, design-oriented metrics, essential for the development of steerable flexible instruments for maxillary sinus surgery, are still lacking. This paper proposes a method to process measurements and provides the instrument designer with essential information to develop adapted flexible instruments for limited access surgery. This method was applied to maxillary sinus surgery and showed that an instrument with a diameter smaller than 2.4 mm can be used on more than 72.5% of the subjects’ set. Based on the statistical analysis and provided that this flexible instrument can bend up to $$164.4^\circ,$$ it is estimated that all areas within the maxillary sinus could be reached through a regular antrostomy without resorting to extra incision or tissue removal in 94.9% of the population set. The presented method was partially validated by conducting cadaver experiments.

BACKGROUND A minimal access technique for the management of nasopharyngeal tumors extending below the palatal plane and laterally beyond the pterygoid musculature is yet to be developed. In this study we demonstrate the feasibility of endoscopic transoral nasopharyngectomy (ETON) for resection of large nasopharyngeal lesions as a natural orifice alternative to traditional approaches. METHODS ETON was completed in three latex-injected specimens. Surgical freedom (SF) and angles of attack (AoA) were calculated along the internal carotid artery (ICA). RESULTS An endoscopic transoral approach was successfully used to identify the parapharyngeal ICA and subsequently perform a complete nasopharyngeal resection. SF and AoA (sagittal) were found to be the greatest at the anterior genu of the ICA. CONCLUSIONS ETON is feasible. It provides wide exposure of the skull base and proximal control of the ICA. It may be indicated for the management of nasopharyngeal tumors with inferolateral extension, involving the ICA.

Objective After significant restrictions initially due to the COVID-19 pandemic, otolaryngologists have begun resuming normal clinical practice. However, the risk of SARS-CoV-2 transmission to health care workers through aerosolization and airborne transmission during rhinologic surgery remains incompletely characterized. The objective of this study was to quantify the number concentrations of aerosols generated during rhinologic surgery with and without interventions involving 3 passive suction devices. Study Design Cadaver simulation. Setting Dedicated surgical laboratory. Subjects and Methods In a simulation of rhinologic procedures with and without different passive suction interventions, the concentrations of generated aerosols in the particle size range of 0.30 to 10.0 µm were quantified with an optical particle sizer. Results Functional endoscopic sinus surgery with and without microdebrider, high-speed powered drilling, use of an ultrasonic aspirator, and electrocautery all produced statistically significant increases in concentrations of aerosols of various sizes (P < .05). Powered drilling, ultrasonic aspirator, and electrocautery generated the highest concentration of aerosols, predominantly submicroparticles

Objective Patients suffering from persistent inferior turbinates hypertrophy refractory to medical treatments require surgical intervention where the main aim is symptomatic relief without any complications. Extraturbinoplasty is one of the preferred procedures for turbinate reduction due to its efficacy in freeing up nasal space by removing the obstructing soft tissue and bone while preserving the turbinate mucosa. We sought to evaluate the effectiveness and safety of microdebrider assisted turbinoplasty (MAT) and coblation assisted turbinoplasty (CAT) performed as an extraturbinoplasty procedure. Methods A prospective randomized comparative trial was conducted among patients with bilateral nasal blockage secondary to inferior turbinates hypertrophy. Patients were randomly assigned to MAT or CAT. An extraturbinal medial flap turbinoplasty was performed for both techniques. Symptom assessment was based on the visual analogue score for nasal obstruction, sneezing, rhinorrhea, headache and hyposmia. Turbinate size, edema and secretions were assessed by nasoendoscopic examination. The assessments were done preoperatively, at 1st postoperative week, 2nd and 3rd postoperative months. Postoperative morbidity like pain, bleeding, crusting and synechiae were documented. The clinical outcomes of both techniques were analyzed using repeated measures ANOVA. Results A total of 33 participants were recruited, 17 patients randomized for MAT and 16 patients for CAT. Nasal obstruction, discharge, sneezing, headache and hyposmia significantly reduced from 1st week until 3 months for both procedures. Similar significant reductions were seen for turbinate size, edema and secretions. However, there was no significant difference in symptoms and turbinate size reduction were seen between both groups at the first postoperative week, 2nd and 3rd postoperative months. There was significant longer operating time for CAT when compared to MAT (p = 0.001). The postoperative complications of bleeding, crusting and synechiae did not occur in both groups. Conclusion Both MAT and CAT were equally effective in improving nasal symptoms and achieving turbinate size reduction in patients with inferior turbinate hypertrophy. Both MAT and CAT offer maximal relieve in patients experiencing inferior turbinates hypertrophy by removing the hypertrophied soft tissue together with the turbinate bone without any complications.

Objectives: A wide and evolving range of lasers and their applications often makes it difficult for a busy surgeon to choose the ideal laser for a specific indication. With this in mind, this article aims to summarize the most recent literature concerning laser application in rhinology. Methods: A literature search from 2000 to 2020 using the PubMed database was employed. Keywords used included “laser,” “rhinology,” “endonasal endoscopic surgery,” “hereditary haemorrhagic telangiectasia,” “rhinitis,” “refractory rhinitis,” “Inferior turbinate hypertrophy,” “dacryocystorhinostomy,” “septoplasty,” “cartilage reshaping” and “choanal atresia.” The most up to date studies published for each rhinology condition that could potentially be treated with laser surgery was included. Results: Rhinological conditions appropriate for laser applications are discussed. We identified articles related to a number of applications including hereditary hemorrhagic telangiectasia, rhinitis, turbinate surgery, dacryocystorhinostomy, septoplasty, choanal atresia, and sphenopalatine artery ligation, paying attention to the outcomes of the studies and their limitations. Conclusions: There is currently no one-size-fits-all laser and therefore being up to date on the latest clinical application results can help the clinician decide which are the best treatments to offer their patients.

Purpose In-office rhinologic procedures have become popularised in the last decade, especially in North America. Endoscopic nasal polypectomy under local anaesthesia offers instant relief in selected patients with obstructive chronic rhinosinusitis with nasal polyps. We aimed to analyse patient tolerability during the procedure while measuring its effectiveness. Methods A prospective study of patients who underwent in-office microdebrider-assisted polypectomy under local anaesthetic from September 2018 to November 2019 in a Spanish tertiary hospital was performed. The tolerability was measured by monitoring vital signs during the procedure and using a visual analogue scale posteriorly. The effectiveness was calculated through patient-reported outcomes (SNOT-22) and endoscopic evaluation 1 and 6 months follow-up. Results Forty-four patients were included, with a mean age of 60.7 years. The mean visual analogue scale score was 2.76 out of 10 points. Vital signs were steady overall, with a statistically significant reduction (p

OBJECTIVES Oral corticosteroid (OCS) as a part of appropriate medical therapy (AMT) (formerly maximal medical therapy) in chronic rhinosinusitis remains controversial. While the risks of OCS are well known, the benefit remains unclear due the absence of a standardized prescribing regimen. Consequently, it is difficult to characterize whether the risks of OCS and its ability to avert endoscopic sinus surgery (ESS) are helpful in AMT. When OCS is highly effective at averting surgery, the lesser risks of OCS would be justified because it can avoid the greater risks of ESS. When OCS is poorly effective at averting ESS, the risks of OCS would not be justified because many patients will be exposed to both risks. This study seeks to identify the threshold effectiveness of OCS at averting ESS that would minimize risk exposure to patients. METHODS A probabilistic risks-based decision analysis was constructed from literature reported incidences and impacts of adverse events of OCS and ESS. Monte Carlo analysis was performed to identify the minimum effectiveness required to avoid further intervention (MERAFI) for chronic sinusitis without nasal polyp (CRSsNP) and chronic sinusitis with nasal polyp (CRSwNP). RESULTS The analysis showed MERAFI results of 20.8% (95% CI 20.7-20.9%) for CRSsNP and 16.8% (95% CI 16.7-16.9%) for CRSwNP. CONCLUSIONS Given reported OCS effectiveness in the range of 34-71% in CRSsNP and 46-63% in CRSwNP, this analysis suggests that the inclusion of OCS in AMT may be the lower risk strategy. LEVEL OF EVIDENCE N/A Laryngoscope, 131:473-481, 2021.

Objective(s): Negative pressure pulmonary edema (NPPE) is a rare perioperative complication with a potentially fatal outcome. The aim of this study was to perform a systematic review of NPPE in adult otolaryngology procedures with the goal of identifying risk factors, clinical presentation, diagnosis, management and outcomes. Methods: Systematic review performed using PubMed, Scopus, Web of Science, and Cochrane databases. Results: Sixty-nine studies including data from 87 individual patients were included in this review. Fifty-six (68%) patients were male and the average patient age was 37 years old. Type 1 NPPE occurred in 63 (72%) cases, while type 2 NPPE accounted for 20 (23%) cases. The most common procedures leading to NPPE were septoplasty, rhinoplasty or sinus surgery (n = 22, 25%), directly laryngoscopy or bronchoscopy (n = 13, 15%), and tracheostomy or cricothyroidotomy (n = 11, 13%). The most employed treatment options included diuretics (n = 55, 63%) and mechanical ventilation (n = 54, 62%). Seventy-eight (90%) patients made a full recovery with an average time to NPPE resolution of 33 hours and an average length of hospitalization of 5.6 days. Five (6%) patients had a long-term morbidity and four (5%) patients died, with age and ICU stay increasing risk for death and long-term morbidity (OR 1.044 and 7.42, respectively, P Conclusion: Septoplasty, rhinoplasty and sinus surgery account for the majority of NPPE cases in adult otolaryngology procedures. Young, healthy patients are the most commonly involved with a slight male predominance. The vast majority of patients recover fully, however there is a significant risk for morbidity and mortality.

Objectives: Changes in airflow dynamics after nasal surgery may have implications on voice quality. Multiple studies have evaluated the impact of nasal surgery on voice using heterogeneous outcome measures. We aim to systematically review the impact of nasal surgery on voice quality. Methods: Our study design was a systematic review with meta-analyses. A literature search of PubMed, Ovid, Cochrane from 1997 to 2017 was performed. Inclusion criteria included English language studies containing original data on nasal surgery and voice. Two investigators independently reviewed all manuscripts and performed a comprehensive quality assessment. Meta-analysis was completed on quantitative voice measurements. Results: Of 463 identified, 19 studies with 692 patients fulfilled eligibility. Nasal surgeries performed included endoscopic sinus surgery (11/20), septoplasty (11/20), rhinoplasty (2/20), and turbinate reduction (2/20). Voice outcomes measured included nasalance (8/20), fundamental frequency (11/20), jitter (10/20), shimmer (10/20), harmonic to noise ratio (HRN) (8/20), formants (5/20), and voice handicap index (VHI) (4/20). Voice examinations were assessed preoperatively and 1 to 30 months postoperatively. Meta-analysis revealed statistically significant changes in nasalance, ( P Conclusions: There may be a short-term increase in nasalance that resolves at longer follow-up, but there seem to be no other objective changes in voice. There may be subjective changes after surgery, but require further study to evaluate.

The coronavirus disease 2019 (COVID-19) pandemic disrupted the standard management paradigms for care of patients with sinus and skull base presentations due to concern for patient and health care provider safety, given the high aerosol-generating potential of endonasal procedures.We reviewed the relevant literature complied from available sources, including PubMed, Google Scholar, and otolaryngology journals providing electronic manuscripts ahead of indexing or publication.Incorporating available evidence and the projected infection control and resource limitations at our institution, we collectively authored a dynamic set of protocols guiding (1) case stratification, (2) preoperative assessment, (3) operative setup, and (4) postoperative care of patients with sinus or skull base presentations. Due to the rapidly evolving nature of COVID-19 publications, lack of rigorous data, and urgent necessity of standardized protocols, strict inclusion and exclusion criteria were not employed.As scarce hospital resources are diverted to COVID-19 care and staff are redeployed to forward-facing roles, endonasal procedures have largely ceased, leaving patients with ongoing sinonasal and skull base complaints untreated. Skull base teams now weigh the urgency of surgery in this population with the regional availability of resources.The COVID-19 pandemic will have an enduring and unpredictable impact on hospital operations and surgical skull base practices and will require a dynamic set of management protocols responsive to new evidence and changing resources. In the current resource-limited environment, clinicians may utilize these protocols to assist with stratifying patients by acuity, performing preoperative assessment, and guiding peri- and postoperative care.

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).

BACKGROUND: Chronic rhinosinusitis symptomatology begins in early childhood individuals with cystic fibrosis (CF). Cystic fibrosis transmembrane conductance regulator (CFTR) function contributes to sinus development and disease. Genetic variants of the bitter taste receptor TAS2R38 have been suggested to contribute to sinus disease severity in individuals without CF. Our objective was to explore whether functional TAS2R38 haplotypes and CFTR function are associated with sinus disease or the need for sinus surgery in individuals with CF. METHODS: We conducted a retrospective study using prospectively collected data from the CF Twin-Sibling Study. The function of cystic fibrosis transmembrane conductance regulator (CFTR) was assessed via chloride conductance. Genotyping of the TAS2R38 gene identified patients who were homozygous for the functional haplotype, heterozygous, or homozygous for nonfunctional haplotypes. Clustered multivariate logistic regression was performed, controlling for sex and family relationship. RESULTS: A total of 1291 patients were evaluated. Patients with ≤1% CFTR function were 1.56 times more likely to require sinus surgery than those with >1% CFTR function (P = 0.049). CFTR function did not significantly correlate with the presence of sinus disease (P = 0.30). In addition, there were no statistically significant differences in diagnosis of sinus disease or need for sinus surgery between patients with functional and non-functional TAS2R38 haplotypes. CONCLUSIONS: CFTR function correlates to need for sinus surgery, whereas TAS2R38 function does not appear to contribute to sinus disease or the need for sinus surgery in patients with CF.

Background Endoscopic sinus surgery (ESS) is a variable combination of individual procedures. Cost estimates for ESS as a single entity have wide variation, likely influenced by variation in procedures performed. We sought to identify operative time, supply costs, and total procedure cost specific to the component procedure combinations comprising ESS.Methods Bilateral ESS cases at 13 Intermountain Healthcare facilities (2008 to 2016) were identified from a database with corresponding cost and time data. Procedure details were obtained by chart review. Least-squares (LS) means of cost (in 2016 US dollars) and time for specific procedures were obtained by multivariable gamma regression models.Results Among 1477 bilateral ESS cases with 19 different procedure combinations, operative time ranged from 59.5 (95% confidence interval [CI], 48.6-73.0) minutes for total ethmoid to 147.1 (95% CI, 126.4-171.2) minutes for full ESS with maxillary and sphenoid tissue removal. Sphenoidotomy had lowest total and supply costs (in US dollars) of $2112 (95% CI, $1672-$2667) and $636 (95% CI, $389-$1040), respectively. Total cost was highest for full ESS with maxillary tissue removal at $4640 (95% CI, $4115-$5232). Supply cost was highest for full ESS with maxillary and sphenoid tissue removal at $2191 (95% CI, $1649-$2909).Conclusion Operative time and costs for ESS vary depending on the procedures performed, demonstrating the importance of procedure specificity in assessment of ESS time, cost, and, ultimately, value. These procedure-specific estimates of cost enable nonbinary valuation of ESS, appropriate for the multitude of procedure options intended to optimize individual outcomes.

BACKGROUND Excess opioid use after surgery contributes to opiate misuse and diversion. Understanding opioid prescribing and utilization patterns after sinonasal surgery is critical in designing effective practice protocols. In this study we aim to identify factors associated with variable opioid usage and further delineate optimal prescription patterns for sinonasal surgery. METHODS All patients undergoing sinonasal surgery within a single health-care system from March 2017 to August 2018 were sent electronic postoperative surveys. Data were collected on the amount of opioid required, pain control, presurgical opiate use, and narcotic disposal. Additional data collected from the electronic medical record included demographics, type of surgery performed, and total amount of opioid prescribed, including refills. RESULTS Three-hundred sixty four patients were included. A mean number of 25.3 tablets were prescribed per patient, yet the mean taken was just 11.8 tablets. Excess opioids were prescribed 84.9% of the time with a mean excess narcotic in oral morphine equivalents of 152.5. Among patients, 11.8% reported using no opioids, whereas 52.1% used 50% of their narcotic prescription. Patients used 9.3% of their full prescription and only 2.6% required a refill. The amount used was not associated with complexity of endoscopic sinus surgery, type of opiate prescribed, gender, distance living from hospital, or current opioid usage before surgery (p > 0.05). The addition of septoplasty and/or turbinoplasty was associated with variation in opioid usage (p < 0.001). A total of 76.1% of patients incorrectly discarded/stored excess opiates. CONCLUSION Opioids are overprescribed after sinonasal surgery. The amount of postoperative opiate prescribed should be greatly reduced and may be based on the specific procedures performed. Improved patient education regarding disposal of excess narcotics may help to curtail future opioid diversion.

Background: Chronic rhinosinusitis (CRS) is a chronic inflammatory disease of the sinonasal mucosa and with strong associations to other immune-mediated comorbidities. Patients often require referral to both an otolaryngologist and an allergist/immunologist. This study is the first in the literature to describe a multidisciplinary clinic that offers patient care by subspecialists in rhinology and in allergy/immunology. Methods: One hundred twenty-nine patients were seen in the Comprehensive Sinus and Allergy Clinic (CSAC) between January 2016 and June 2017 and 43 selected patients were seen in both the standalone allergy and rhinology clinics over the same time period. Patient satisfaction was retrospectively assessed using a modified Press-Ganey satisfaction survey. Time to evaluation and time to follow up appointment were compared between the CSAC and both the standalone rhinology and allergy/immunology clinics. Results: Patients seen in the CSAC reported high satisfaction with the amount of time spent with the physicians (98.3%), quality of medical care (9.3 ± 1.0), and most importantly, the convenience of seeing two physicians in one day (9.5 ± 1.2). Time from referral placement to clinic evaluation ( P ≤ .02) and time to follow up appointment ( P ≤ .002) was significantly shorter for the CSAC than for the standalone Rhinology or Allergy clinics. Conclusion: Patients reported high satisfaction with the medical care provided and were also seen much faster in our multidisciplinary clinic as compared to standalone rhinology or allergy/immunology clinics. Overall, a multidisciplinary approach may be beneficial to patients presenting to tertiary referral centers with CRS and atopic conditions.

Il trattamento endoscopico dell’atresia coanale e utilizzo delle dilatazioni mediante balloon: nostra esperienza.Scopo di questo studio è quello di descrivere i risultati della nostra esperienza nel trattamento chirurgico endoscopico della atresia coanale e di illustrare in particolare il nostro protocollo che per mantenere pervio lo spazio coanale non prevede l’applicazione di uno stent ma dilatazioni endoscopiche mediante balloon ripetute nel post-operatorio al fine di stabilizzare il risultato chirurgico. Nel periodo compreso fra dicembre 2014 e dicembre 2018, abbiamo arruolato 46 pazienti affetti da atresia coanale e sottoposti a trattamento chirurgico presso l’Unità di Otorinolaringoiatria dell’Ospedale Pediatrico Bambino Gesù (17 con atresia coanale bilaterale e 29 con atresia coanale monolaterale), Tutti i pazienti sono stati sottoposti a chirurgia endoscopica transnasale. L’incisione della mucosa è stata realizzata con strumentazione a freddo e a caldo (laser a diodi). L’eliminazione della componente ossea è stata possibile mediante l’utilizzo di frese; la calibrazione delle neo-coane è stata eseguita con la tecnica di dilatazione mediante balloon. Nessuno stent è stato utilizzato e nessun paziente ha ricevuto trattamento topico con mitomicina. Il primo controllo endoscopico post-operatorio con eventuale dilatazione è stato eseguito 7 giorni dopo la procedura chirurgica. Una seconda valutazione endoscopica con medicazione e dilatazione è stata effettuata 15 giorni al fine di stabilizzare il risultato chirurgico. Ulteriori controlli sono stati pianificati ad un mese dall’intervento e i successivi sulla base dei progressi del singolo paziente. In nessuno dei 46 pazienti trattati abbiamo osservato complicanze dopo i trattamenti endoscopici. L’età media dei 17 pazienti con atresia coanale bilaterale è stata di 10,4 giorni al momento del primo trattamento; nel 64% dei casi l’atresia era associata ad altre anomalie. Il protocollo terapeutico ha garantito il raggiungimento di outcome soddisfacenti nell’82% dei casi, con una media di 4.6 procedure realizzate per ogni paziente (range: 3-11). I 29 pazienti affetti da atresia monolaterale presentavano un’età media di 36,6 mesi al primo trattamento, una prevalenza di atresia monolaterale destra (11:6), un’associazione con ulteriori anomalie nel 27% dei casi. Abbiamo ottenuto una percentuale di successo dell’85,7% con una media di 3,5 procedure per paziente (range: 3-7). La chirurgia endoscopica transnasale è attualmente considerata il gold standard terapeutico, sia per l’atresia monolaterale che bilaterale. A nostro parere, andrebbe evitato l’utilizzo di stent post-intervento, anche se ancora oggi vengono utilizzati; la recidiva è ridotta dall’utilizzo della dilatazione mediante balloon che, nella nostra esperienza, è un valido aiuto sia nel trattamento dell’atresia primaria che delle recidive.The aim of this study is to report our experience in surgical treatment of unilateral and bilateral choanal atresia. We describe the endoscopic surgical technique for creation of neo-choanes and following repeating balloon dilation after surgery to stabilise the results. The study was carried out from December 2014 to December 2018, enrolling 46 patients who underwent surgery for choanal atresia at the Otolaryngology Unit of the Paediatric hospital Bambino Gesù: 17 with bilateral choanal atresia (Group A) and 29 with unilateral choanal atresia (Group B). All patients underwent transnasal endoscopic surgery. The incision of the mucosa was made with a cold and hot system (laser diode). The elimination of atresic plaque was possible thanks to the use of a drill; the calibration of the neo-choanes was carried out with the help of balloon dilation. No stent was used, and no patient underwent treatment with topical mitomycin. The first endoscopic follow-up was made 7 days after surgery with surgical curettage and a second balloon dilation 15 days after surgery to stabilise the new choanes. Further check-ups were suggested at 1 month after surgery and later based on individual progress. In group A, the average age for the first treatment was 10.4 days, and atresia was associated with other anomalies in 64% of cases. The therapeutic protocol led to a successful outcome in 82% of cases, with an average of 4.6 procedures per patient (range: 3-11). In group B, the average age for the first treatment was 36.6 months, association with other anomalies was 27% of cases and the prevalent side was the right (11:6). We obtained surgical success in 85.7% of cases and the average number of endoscopic dilations was 3.5 (range: 3-7). Transnasal endoscopic surgery is now considered the therapeutic gold-standard for both unilateral and bilateral atresia. Even if still used, post-surgery stenting can be avoided in our opinion; relapse is reduced with the use of balloon dilation, which, in our experience, is a valid aid in both primary atresia treatment and in cases of relapse.

To evaluate the acquisition of surgical skills by otolaryngology residents and established the minimum number of dissections of a lamb's model to be performed before practicing on human patients.Nineteen second-year otolaryngology residents performed ten dissections each, five on each nasal cavity, always practicing the same three surgical procedures on the lamb model. Each student's training lasted 2-months, and the entire training intervention lasted 4-years, over four generations of residents. All dissections were recorded and were selected at random for examination by two independent otolaryngology surgeons, who were otherwise not involved in the research. Assessment of the 190 dissections used an instrument validated for surgical training of medical residents.To a 1% significance level, statistical analysis revealed increased performance and satisfactory results were observed after the sixth dissection. Furthermore, after the eighth dissection, skill acquisition was relevant and sustained.Training in endoscopic nasal surgery on a lamb's head model improves surgical skills and handling of surgical instruments. Our results showed the relevance of the lamb model for training in otolaryngology surgery, impacting on patient safety.

To investigate the effects of nasal surgery including endoscopic sinus surgery (ESS) and/or septoplasty on Eustachian tube dysfunction (ETD) symptoms using the Eustachian Tube Dysfunction Questionnaire 7 (ETDQ-7).Patients who underwent ESS and/or septoplasty between April 2020 and October 2021 were retrospective reviewed. The patients were divided into 3 groups according to the type of surgery: group A, septoplasty alone (76 patients); group B, ESS alone (209 patients); and group C, septoplasty + ESS (74 patients). Responses to the ETDQ-7, SNOT-22, and NOSE questionnaires were collected preoperatively and at 3 months after surgery and compared between groups.A total of 359 patients were included in the study. The prevalence of ETD was 28.9% (22 patients) in group A, 27.3% (57 patients) in group B, and 31.1% (23 patients) in group C. The ETDQ-7 score decreased significantly after surgery: total patient population, 12.47 ± 7.0 to 8.2 ± 2.48 (p 0.001); group A, 12.76 ± 6.62 to 8.47 ± 2.66 (p 0.001); group B, 12.05 ± 6.89 to 8.35 ± 2.73 (p 0.001); and group C, 13.24 ± 7.72 to 7.55 ± 1.25 (p 0.001). Both SNOT-22 and NOSE scores also decreased significantly after surgery in the total patient population and in all three groups. There was a strong correlation between ETDQ-7 and SNOT-22 scores (r = 0.56, p 0.001) and a moderate correlation between ETDQ-7 and NOSE scores (r = 0.33, p 0.001).Patients with CRS and/or NSD suffered from ETD, and showed significant improvement after surgery. In addition, ETD symptoms were shown to be affected by nasal obstruction as well as CRS symptoms.

In endoscopic maxillary sinus surgery, the maxillary sinus is accessed through the nasal cavity which constitutes a narrow and tortuous pathway. However, surgeons still use rigid endoscopes and rigid, straight or pre-bent instruments for this procedure. Resection of the uncinate process and creation of a medial antrostomy is warranted to access the pathology inside the maxillary sinus and depending on the location of the pathology (lateral, inferior or anterior wall), additional resection of healthy tissue and/or functional structures like the lacrimal duct and/or inferior turbinate is necessary to gain optimal access. In order to avoid this additional resection, a functional single-handed, steerable endoscope for endoscopic maxillary sinus surgery has been designed and built. This endoscope is, to our knowledge, the most slender active steerable endoscope ever reported for maxillary sinus surgery. The performance of the endoscope was validated by two surgeons on a cadaver. An increased field of view was found in comparison to currently used endoscopes. As a direct consequence, a reduced need for resection of healthy tissue was confirmed. ispartof: Scientific Reports vol:12 issue:1 ispartof: location:England status: Published online

ObjectiveTo describe the utility of sleep nasendoscopy in determining the level of upper airway obstruction compared to microlaryngotracheobronchoscopy.MethodsA retrospective observational study was conducted at a tertiary level paediatric hospital. Patients clinically diagnosed with upper airway obstruction warranting surgical intervention (i.e. with obstructive sleep apnoea or laryngomalacia) were included. These patients underwent sleep nasendoscopy in the anaesthetic room; microlaryngotracheobronchoscopy was subsequently performed and findings were compared.ResultsTwenty-seven patients were included in the study. Sleep nasendoscopy was able to induce stridor or stertor, and to detect obstruction at the level of palate and pharynx, including tongue base collapse, that was not observed with microlaryngotracheobronchoscopy. Only 47 per cent of patients who had prolapse or indrawing of arytenoids on sleep nasendoscopy had similar findings on microlaryngotracheobronchoscopy. However, microlaryngotracheobronchoscopy was better in diagnosing shortened aryepiglottic folds.ConclusionThis study demonstrates the utility of sleep nasendoscopy in determining the level and severity of obstruction by mimicking physiological sleep dynamics of the upper airway.

Objective The role of isolated nasal surgery for obstructive sleep apnea (OSA) patients with nasal obstruction, especially for an intolerance for continuous positive airway pressure (CPAP), is unclear. The aim of this study was to assess the effects of surgery for OSA patients with symptomatic nasal obstruction and CPAP intolerance. Method Retrospectve comparative study.1037 OSA patients with apnea-hypopnea index (AHI) ≥ 20 were enrolled. Case-control study was performed between the male apnea patients undergoing nasal surgery: surgery group (n = 43) and the pair-matched apnea patients for age, sex, body mass index, and race: control group (n = 43). The surgery group suffering from nasal obstruction could not use continuous positive airway pressure, and the CPAP group free from nasal obstruction could use it successfully. Results In surgery group, surgery significantly decreased the nasal resistance and Epworth sleepiness scale scores without changing the AHI. Surgery significantly increased the nadir of oxygen saturation and shortened the apnea-hypopnea duration. Although all of the surgery group failed to use positive airway pressure preoperatively, the 40 patients of the 43 CPAP intolerance patients were able to use CPAP postoperatively. The resting three patients were cured OSA or changed the treatment to oral appliance(OA). For both groups, the cutoff nasal resistance for differentiating the failure of positive airway pressure and its success was 0.31 Pa/cm3/s. Conclusion Isolated nasal surgery is effective for an intolerance of positive airway pressure in sleep apnea with nasal obstruction presumably by decreasing nasal resistance.

ObjectiveThere are gaps within current meta-analyses looking at the effects of tranexamic acid on sino-nasal surgery. This study aimed to update and summarise all current available evidence on the use of tranexamic acid in sino-nasal surgery.MethodA literature search was performed using four medical databases, Cochrane Library, Embase, Medline and PubMed. Data analysis was performed using dedicated meta-analysis software Review Manager (Revman).ResultsThirteen studies were included in the meta-analysis. The amount of blood loss and duration of surgery in tranexamic acid groups was statistically lower than placebo for both sinus and nasal surgery. Tranexamic acid improves the surgical field quality in sinus surgery but worsens the field in nasal surgery. Topical or intravenous administration of tranexamic acid in sinus surgery reduces blood loss, duration of surgery and improves the quality of the surgical field.ConclusionThis study suggests that the use of tranexamic acid in sinus surgery reduces blood loss, decreases surgical duration and improves surgical field quality.

Respiratory condition could worsen during sleep in patients with nasal packing following endoscopic nasal and sinus surgery (ESS) under general anesthesia. Recently, a noninvasive intrathoracic pressure estimation sensor was developed that uses photoplethysmographic pulse wave technology. The purpose of this study was to noninvasively evaluate the effect of bilateral nasal packing on respiration during sleep, using a photoplethysmographic pulse wave sensor in perioperative patients who underwent ESS under general anesthesia.In this observational cross-sectional case-control study, estimated intrathoracic pressure and SpOSignificant changes were noted in estimated intrathoracic pressure, but not in SpOUse of the photoplethysmographic pulse wave sensor to noninvasively measure intrathoracic pressure detected changes in perioperative respiratory effort that pulse oximetry did not. Attention should be paid to the use of postoperative bilateral nasal packing in patients with moderate to severe OSA who undergo ESS under general anesthesia. Our results support the concept of using less, short-term, or no nasal packing after ESS.

To evaluate and compare the prevalence of high-risk HPV and low-risk HPV types in patients with chronic rhinosinusitis with nasal polyposis (CRSwNP) and healthy controls.A prospective cohort study was conducted in a tertiary care hospital on the patients of CRSwNP undergoing surgical management. All patients underwent preoperative endoscopic evaluation and radiological assessment using NCCT of the nose and paranasal sinuses. The severity of the disease was graded using the Lund-Mackay score on NCCT. All patients underwent endoscopic polypectomy and the sample of tissues was sent for HPV DNA detection using Hybrid Capture II® technique. The clinicopathological characteristics of HPV positive and negative patients were compared.Sixty cases and 20 controls were included in the study. All controls were negative for HPV DNA. 27 patients (45%) had the presence of HPV DNA, out of which 23 had only LR-HPV and 1 had only HR-HPV types. Three patients had both HR-HPV and LR-HPV subtypes. There was a significant difference between the cases and controls for the presence of HPV DNA (p 0.001). However, the patients with HPV-positive DNA in the nasal specimen did not differ significantly from HPV-negative patients in age, gender, or severity of the disease.Human papillomaviruses may play a significant role in the etiopathogenesis of CRSwNP, however, do not impact the degree of sinus involvement.

Purpose One of the most common complications after septoplasty is a postoperative infection. We investigated the number of postoperative infections and unplanned postoperative visits (UPV) in septoplasties with and without additional nasal surgery at our institution and evaluated the role of antibiotic prophylaxis. Methods We collected data of all consecutive 302 septoplasty or septocolumelloplasty patients operated during the year 2018 at the Department of Otorhinolaryngology-Head and Neck Surgery, HUS Helsinki University Hospital (Helsinki, Finland). Hospital charts were reviewed to record sociodemographic patient characteristics and clinical parameters regarding surgery and follow-up. Results Altogether 239 patients (79.1%) received pre- and/or postoperative prophylactic antibiotics and within this group 3.3% developed a postoperative infection. The infection rate in the non-prophylaxis group of 63 patients was 12.7% (p = 0.007). When all patients who received postoperative antibiotics were excluded, we found that the infection rate in the preoperative prophylaxis group was 3.8%, as opposed to an infection rate of 12.7% in the non-prophylaxis group (p = 0.013). When evaluating septoplasty with additional sinonasal surgery (n = 115) the rate of postoperative infection was 3.3% in the prophylaxis group and 16.7% in the non-prophylaxis group (p = 0.034). These results show a statistically significant stand-alone effect of preoperative prophylactic antibiotics in preventing postoperative infection in septoplasty, especially regarding additional sinonasal surgery. Conclusion The use of preoperative antibiotics as a prophylactic measure diminished statistically significantly the rate of infections and UPVs in septoplasty when all postoperative infections, superficial and mild ones included, were taken into account.

Our understanding of empty nose syndrome (ENS) continues to evolve. Prior studies evaluating airway augmentation to treat ENS did not use validated disease-specific questionnaires, making the true impact of these surgeries unclear. We present a case series of 10 patients with ENS (11 procedures) who underwent the inferior meatus augmentation procedure (IMAP) between September 2014 and May 2017. Subjective outcomes of IMAP included comparisons of preoperative and postoperative assessments (1 week, 1 month, 3 months, 6 months) using the Empty Nose Syndrome 6-item Questionnaire (ENS6Q), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder 7-item Scale (GAD-7), and Sino-Nasal Outcome Test-22 (SNOT-22). The decrement in ENS6Q scores observed maintained statistical significance at 6 months (P ≤ .001). Similar results were achieved with PHQ-9, GAD-7, and SNOT-22 (P ≤ .01, P ≤ .01, P ≤ .001, respectively). IMAP can dramatically improve the quality of life of ENS patients regarding both ENS-specific symptoms and psychological well-being.

Congenital nasolacrimal duct cyst (NLDC) is a rare disorder, which can present with ophthalmological and nasal signs and symptoms. The authors analyse their personal experience to identify diagnostic criteria for NLDC, which were treated by endoscopic transnasal procedure.Clinical records of patients with a diagnosis of NLDC were retrospectively reviewed. All patients underwent rhinoscopy and ophthalmologist evaluation before surgery, whereas imaging was performed in selected cases. All neonates underwent transnasal endoscopic marsupialisation after failure of conservative medical therapy.Five patients were included in the study. One patient presented bilateral NLDC. In 3 cases, CT scan of the sinus was carried out. A total of 6 marsupialisation procedures were performed and a bi-canalicular lacrimal stent was positioned in 1 case. Complete remission of symptoms was observed in all cases.Nasal endoscopy is mandatory to diagnose NLDCs, and, in some cases, it can be complemented by radiological procedures. When symptoms persist after systemic and topical therapy, nasal endoscopic marsupialisation is the treatment of choice. This surgical procedure is effective, safe and can be repeated if needed.Il trattamento delle cisti congenite del dotto nasolacrimale: il ruolo della marsupializzazione endoscopica.La cisti congenita del dotto nasolacrimale (CDNL) è una condizione rara, che si manifesta con segni e sintomi oftalmologici e nasali. Gli autori analizzano la propria esperienza al fine di identificare criteri diagnostici per la CDNL, trattata con procedura endoscopica transnasale (ET).È stata eseguita un’analisi retrospettiva dei dati clinici dei pazienti affetti da CDNL. I pazienti sono stati sottoposti ad endoscopia nasale (EN) e valutazione oculistica prima dell’intervento, l’imaging è stato eseguito in casi selezionati. Tutti i neonati sono stati sottoposti a marsupializzazione ET dopo fallimento di terapia medica.Cinque pazienti sono stati inclusi nello studio. Un paziente ha presentato CDNL bilaterale. In 3 casi, è stata eseguita TC del massiccio facciale. Sono state eseguite 6 procedure di marsupializzazione; uno stent lacrimale bi-canalicolare è stato posizionato in 1 caso. La remissione completa dei sintomi è avvenuta in tutti i casi.L’EN è chiave per la diagnosi di CDNL e può essere integrata con procedure radiologiche. Quando i sintomi persistono dopo terapia sistemica e topica, la marsupializzazione ET rappresenta il trattamento di scelta. Questa procedura chirurgica è efficace, sicura e può essere se necessario ripetuta.

Introduction: Tranexamic acid is a hemostatic agent, which inhibits fibrin degradation, which may be beneficial in controlling bleeding during surgery. Objectives: The purpose of this study was to provide a meta-analysis and review of the effects of tranexamic acid on hemorrhage and surgical fields and side effects on patients during endoscopic sinus surgery. Methods: Two authors independently searched six databases (Medline, Scopus, Embase, Web of Science, Google Scholar and Cochrane library) from the start of article collection until July 2018. Postoperative complications such as intraoperative bleeding, operative time, hypotension, nausea, vomiting, and coagulation profile were included in the analysis of tranexamic acid (Treatment Group) and placebo (Control Group) during the operation. Results: The amount of blood loss during surgery was statistically lower in the treatment group compared to the placebo group, and the surgical field quality was statistically higher in the treatment group than in the placebo group. On the other hand, there was no significant difference in operation time, hemodynamics, or coagulation profile between groups. In addition, tranexamic acid had no significant effect on vomiting and thrombosis compared to the Control Group. Conclusion: This meta-analysis has shown that topical administration of tranexamic acid can reduce the amount of bleeding during surgery and improve the overall quality of the surgery. Hemodynamic instability during surgery, vomiting after surgery, or abnormal clotting profile were not reported. Additional studies are needed to confirm the results of this study because there are fewer studies. Resumo: Introdução: O ácido tranexâmico é um agente hemostático, que inibe a degradação da fibrina e pode ser benéfico no controle do sangramento durante a cirurgia. Objetivos: Fazer uma metanálise e revisão dos efeitos do ácido tranexâmico na hemorragia e nos campos cirúrgicos e efeitos colaterais em pacientes durante a cirurgia endoscópica do seio nasal. Método: Dois autores realizaram independentemente uma busca em seis bancos de dados (Medline, SCOPUS, Embase, Web of Science, Google Scholar e Cochrane) desde o início da coleta de artigos até julho de 2018. Complicações pós-operatórias como sangramento intraoperatório, tempo operatório, hipotensão, náusea, vômitos e perfil de coagulação foram incluídos na análise do ácido tranexâmico (grupo de tratamento) e placebo (grupo controle) durante a cirurgia. Resultados: A quantidade de perda de sangue durante a cirurgia foi estatisticamente menor no grupo de tratamento comparado com o grupo placebo e a qualidade do campo cirúrgico foi estatisticamente maior no grupo de tratamento do que no grupo placebo. Por outro lado, não houve diferença significante no tempo cirúrgico, hemodinâmica ou perfil de coagulação entre os grupos. Além disso, o ácido tranexâmico não teve efeito significante na ocorrência de vômitos e trombose em comparação ao grupo controle. Conclusão: Esta metanálise mostrou que a administração tópica de ácido tranexâmico pode reduzir a quantidade de sangramento durante a cirurgia e melhorar a qualidade geral dela. Instabilidade hemodinâmica durante a cirurgia, vômitos após a cirurgia ou perfil de coagulação anormal não foram relatados. Estudos adicionais são necessários para confirmar os resultados desta pesquisa, porque há poucos estudos na literatura. Keywords: Tranexamic acid, Endoscopic sinus surgery, Operative bleeding, Systematic review, Meta-analysis, PALAVRAS-CHAVE: Ácido tranexâmico, Cirurgia endoscópica do seio nasal, Sangramento operatório, Revisão sistemática, Metanálise

Background Nasal irrigation is a significant component of effective medical management in patients with chronic rhinosinusitis (CRS). Irrigations facilitate distribution of topical medical therapies to affected mucosal surfaces and lavage of hypersecretory mucin and inflammatory products. Objective To compare the effectiveness of cadaveric nasal irrigation distribution and force following different surgical techniques commonly used to open the maxillary sinus. Methods Fresh human cadaver heads were dissected sequentially with uncinectomy, maxillary antrostomy, endoscopic maxillary mega-antrostomy, and modified endoscopic medial maxillectomy. After each surgical technique was performed, the corresponding nasal cavity was irrigated with 240 mL irrigation bottles containing 1/1000 10% fluroscein-labeled free water. A nasal endoscope passed through the canine fossa into a fixed position in the maxillary sinus recorded the extent of sinus irrigation. These videos then underwent blinded assessment by 2 observers assessing for irrigation sinus penetration (scored as 0–4) and force (0–2). Ordinal correlation scores were assessed using Kendall’s tau-B. Results A total of 17 sinuses (age 53.4 ± 12.6, 36.4% female) were assessed. There was a statistically significant positive correlation between increasing extent of maxillary sinus dissection and both sinus penetration and force as assessed by both observers (Kendall’s tau-B P Conclusion Increasing the extent of surgical dissection appears to improve penetration and force of the nasal irrigation into the maxillary sinus. This study suggests that while a standard maxillary antrostomy may be sufficient to achieve good topical therapy distribution, more extensive surgery such as a modified medial maxillectomy may be required for sufficient force of sinus lavage.

Objectives Evaluate the effect of functional endoscopic sinus surgery (FESS) for nasal polyposis on sleep efficiency and polysomnographic parameters. Subjects and methods This clinical trial was conducted on 15 patients with bilateral massive sinonasal polyposis who underwent FESS between August 2012 and September 2013. All participants were evaluated subjectively by employing the Pittsburgh Sleep Quality Index (PSQI) questionnaire and objectively (provided by polysomnographic parameters) before and 2 months after surgery. Results The evaluation of subjective criteria of sleep quality assessed by PSQI showed significant improvement, particularly in nocturnal awakening (P = 0.002). However, Apnea Hypopnea Index (AHI) was not reduced significantly after surgery (P = 0.233). Among patients who had suffered from obstructive sleep apnea, AHI was improved in 7 patients, deteriorated in 3 patients, and did not change in 1 patient. Although the mean duration of REM sleep stage increased from 15.2 ± 10.7 to 18.9 ± 7.9, this change was not statistically significant. Furthermore, arousal index decreased dramatically from 31.6 to 17.1 (P = 0.02) and sleep efficiency index was improved after the surgery (P = 0.008). Conclusions This study documented the effect of resuming nasal cavity patency on improvement of sleep efficiency after FESS. In spite of insignificant effect of FESS on apnea index, alteration of other sleep parameters like arousal index following surgery may have a positive effect on sleep quality.

BackgroundNasal lavage with mupirocin has the potential to reduce sinonasal morbidity in endoscopic endonasal approaches for skull base surgery.ObjectiveTo evaluate the effects of nasal lavage with and without mupirocin after endoscopic endonasal skull base surgery.MethodsA pilot randomised, controlled trial was conducted on 20 adult patients who had undergone endoscopic endonasal approaches for skull base lesions. These patients were randomly assigned to cohorts using nasal lavages with mupirocin or without mupirocin. Patients were assessed in the out-patient clinic, one week and one month after surgery, using the 22-item Sino-Nasal Outcome Test questionnaire and nasal endoscopy.ResultsPatients in the mupirocin nasal lavage group had lower nasal endoscopy scores post-operatively, and a statistically significant larger difference in nasal endoscopy scores at one month compared to one week. The mupirocin nasal lavage group also showed better Sino-Nasal Outcome Test scores at one month compared to the group without mupirocin.ConclusionNasal lavage with mupirocin seems to yield better outcomes regarding patients’ symptoms and endoscopic findings.