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Objective: Commonly used endoscopic grading scales, such as the nasal polyp scale, inadequately describe the degree of polyposis found postoperatively in the paranasal sinus cavities. The purpose of this study was to create a novel grading system that more accurately characterizes polyp recurrence in postoperative sinus cavities, the Postoperative Polyp Scale (POPS)., Methods: A modified Delphi method was utilized to establish the POPS using consensus opinion among 13 general otolaryngologists, rhinologists, and allergists. Postoperative endoscopy videos from 50 patients with chronic rhinosinusitis with nasal polyps were reviewed by 7 fellowship-trained rhinologists and scored according to the POPS. Videos were rated again 1 month later by the same reviewers, and scores were assessed for test-retest and inter-rater reliability., Results: Overall inter-rater reliability for the first and second reviews of the 52 videos was Kf = 0.49 (95% CI 0.42-0.57) and Kf = 0.50 (95% CI 0.42-0.57) for the POPS. Intra-rater reliability showed near-perfect test-retest reliability for the POPS with Kf = 0.80 (95% CI 0.76-0.84)., Conclusion: The POPS is an easy-to-use, reliable, and novel objective endoscopic grading scale that more accurately describes polyp recurrence in the postoperative state which will be useful in the future for measuring the efficacy of various medical and surgical interventions., Level of Evidence: 5 Laryngoscope, 133:2885-2890, 2023., (© 2023 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective To develop a clinical consensus statement on the use of sinus ostial dilation (SOD) of the paranasal sinuses. Methods An expert panel of otolaryngologists was assembled to represent general otolaryngology and relevant subspecialty societies. The target population is adults 18 years or older with chronic or recurrent rhinosinusitis (with or without nasal polyps, with or without prior sinus surgery) for whom SOD is being recommended, defined as endoscopic use of a balloon device to enlarge or open the outflow tracts of the maxillary, frontal, or sphenoid sinuses, as a standalone procedure or with endoscopic surgery. A modified Delphi method was used to distill expert opinion into clinical statements that met a standardized definition of consensus. Results After 3 iterative Delphi method surveys, 13 statements met the standardized definition of consensus while 45 statements did not. The clinical statements were grouped into 3 categories for presentation and discussion: (1) patient criteria, (2) perioperative considerations, and (3) outcomes. Strong consensus was obtained for not performing SOD in patients without sinonasal symptoms or positive findings on computed tomography (CT) in patients with symptoms only of headache or sleep apnea without criteria for sinusitis. In addition, strong consensus was met that CT scan of the sinuses was necessary before performing SOD and that surgeons need to understand and abide by regulations set forth by the US Food and Drug Administration if they choose to reuse/reprocess devices. Conclusion Expert panel consensus may provide helpful information for the otolaryngologist considering the use of SOD for the management of patients with a diagnosis of rhinosinusitis. This panel reached consensus on a number of statements that defined the use of SOD as inappropriate in the management of a variety of symptoms or diseases in the absence of underlying sinusitis. When patients meet the definition of chronic sinusitis as confirmed by CT scan, SOD of the sinuses can be indicated and/or effective in certain scenarios. Additional consensus statements regarding proper setting and safeguards for performing the procedure are described.

Background: Sellar pathology is increasingly addressed using the expanded endonasal approach (EEA). Although avascular graft reconstruction is an acceptable means to prevent cerebrospinal fluid leak, there are few data regarding sinonasal morbidity in these patients. In this study we compare rates of persistent postoperative crusting (PPC) and rhinosinusitis in patients undergoing sellar reconstruction with mucosal autografting and acellular dermal allografting (ADA)., Methods: Patients undergoing the EEA between 2008 and 2014 were categorized into 2 subgroups: mucosal reconstruction and ADA reconstruction. Univariate analyses were performed to compare differences in PPC and rhinosinusitis in these groups and to identify risk factors for sinonasal morbidity. Multivariate propensity matching analysis was performed to match ADA and mucosa reconstruction groups with respect to age, race, gender, smoking status, diabetes status, tumor type, tumor size, and revision vs primary surgery., Results: A total of 149 patients were identified. There were 105 patients reconstructed with autologous mucosa (70.5%) and 44 reconstructed with ADA (29.5%). Overall, PPC was seen in 20 patients (13.4%) and rhinosinusitis in 10 patients (6.7%). Propensity matching generated 39 patients reconstructed with ADA and 39 reconstructed with mucosa. There was a significant increase in PPC in patients reconstructed with ADA compared to those reconstructed with mucosa (8 of 39 [20.5%] vs 2 of 39 [5.1%], p = 0.04). There was no association between reconstruction with ADA and increased rhinosinusitis (3 of 39 [7.7%] vs 4 of 39 [10.3%], p = 0.64)., Conclusion: Sinonasal morbidity is not uncommon after sellar reconstruction. Patients undergoing sellar reconstruction with ADA may be at increased risk of postoperative crusting compared with those undergoing reconstruction with mucosa., (© 2017 ARS-AAOA, LLC.)

Background: Measuring quality outcomes is an important prerequisite to improve quality of care. Rhinosinusitis represents a high value target to improve quality of care because it has a high prevalence of disease, large economic burden, and large practice variation. In this study we review the current state of quality measurement for management of both acute (ARS) and chronic rhinosinusitis (CRS)., Methods: The major national quality metric repositories and clearinghouses were queried. Additional searches included the American Academy of Otolaryngology-Head and Neck Surgery database, PubMed, and Google to attempt to capture any additional quality metrics., Results: Seven quality metrics for ARS and 4 quality metrics for CRS were identified. ARS metrics focused on appropriateness of diagnosis (n = 1), antibiotic prescribing (n = 4), and radiologic imaging (n = 2). CRS quality metrics focused on appropriateness of diagnosis (n = 1), radiologic imaging (n = 1), and measurement of patient quality of life (n = 2). The Physician Quality Reporting System (PQRS) currently tracks 3 ARS quality metrics and 1 CRS quality metric. There are no outcome-based rhinosinusitis quality metrics and no metrics that assess domains of safety, patient-centeredness, and timeliness of care., Conclusions: The current status of quality measurement for rhinosinusitis has focused primarily on the quality domain of efficiency and process measures for ARS. More work is needed to develop, validate, and track outcome-based quality metrics along with CRS-specific metrics. Although there has been excellent work done to improve quality measurement for rhinosinusitis, there remain major gaps and challenges that need to be considered during the development of future metrics., (© 2017 ARS-AAOA, LLC.)

Background: Acute invasive fungal rhinosinusitis (AIFR) is a fulminant fungal infection seen in patients who are immunocompromised. Due to its rarity, there is little evidence regarding the appropriate antifungal treatment regimen, especially the degree of surgical intervention., Objective: To assess factors that impact short-term survival in AIFR as defined by survival to hospital discharge and to develop a staging system to predict survival and complete surgical resection., Methods: Fifty-four patients with histopathologically diagnosed AIFR who met inclusion criteria were identified between 1984 and 2014. Patient characteristics, disease extent, treatment modality, and short-term survival data were collected. Univariate analysis was performed to assess for factors associated with survival and increased likelihood of surgical resection., Results: Of 52 patients with adequate documentation, 36 (69.2%) survived their hospital stay. Complete surgical resection was the only factor associated with improved survival (survival, 95.5%; p < 0.01). A surgical staging system was proposed to guide probability of complete resection and overall prognosis, with stage I disease limited to the nasal cavity, stage II involving the paranasal sinuses, stage III involving the orbit, and stage IV with skull base or intracranial extension. The χ2 analyses showed a decreased likelihood of complete surgical resection with stage III or IV disease compared with stage I (resection, 90.9%) (stage III resection, 37.5% [p = 0.01]; stage IV resection, 16.7% [p = 0.002]). There was a decreased likelihood of survival associated with increasing disease stage compared with stage I (survival, 100%) (stage II survival, 60% [p = 0.009]; stage III survival, 62.5% [p = 0.02]; stage IV survival, 54.6%, [p = 0.006])., Conclusion: Although further studies are needed to define specific treatment protocols, analysis of these data indicated that endoscopic sinus surgery with the goal of complete surgical resection may provide the best survival outcomes in select patients when complete surgical resection can be performed. Our staging system represents the first attempt to predict surgical success and prognosis in patients with AIFR.

Nasal polyps are semi-translucent mucosal outgrowths of the paranasal sinuses which typically arise in the setting of chronic rhinosinusitis (CRS). Nasal polyps are also associated with asthma, aspirin sensitivity, cystic fibrosis and allergic fungal rhinosinusitis (AFS). The majority of nasal polyps are bilateral and characterized by tissue edema and eosinophil infiltration. Patients with nasal polyps often present with complaints including nasal obstruction, congestion, rhinorrhea or altered sense of smell. The differential diagnosis ranges from benign masses such as schneiderian papilloma, antrochoanal polyp, angiofibroma and encephalocele to malignant neoplasms such as squamous cell carcinoma (SCC), esthesioneuroblastoma, nasal lymphoma and rhabdomyosarcoma. These lesions may have a similar appearance as nasal polyps and particular attention to an alternative diagnosis for nasal polyps should be entertained if the mass is unilateral or congenital in nature. Workup for patients with a unilateral mass should include radiographic imaging, possible biopsy and careful follow-up when appropriate. Here, we review the disease etiology of nasal polyps and describe the approach to the patient with nasal polyps with emphasis on differential diagnosis and workup., (© 2016 S. Karger AG, Basel.)

Background: Chronic rhinosinusitis (CRS) is a prevalent and costly disease that adversely impacts quality of life. As with other chronic diseases, individual and environmental factors impact the disease process. Smoking and secondhand tobacco (SHS) exposures are important risk factors for CRS. However, little is known about the role that physicians play in educating sinusitis patients about this preventable risk. The objective of this study was to characterize physician participation in SHS exposure screening and education., Methods: The study was a community-based, case-control study of non-current smokers in Washington County, MD. One hundred cases with CRS were matched with 100 controls for age, sex, and former smoking status. We interviewed participants using a validated questionnaire that included questions on physician inquiry and recommendations pertaining to smoking and SHS exposure., Results: Over 80% of participants with CRS recalled their physician inquiring about their current smoking status, whereas only 27% recalled being asked by their physician about SHS exposure and only 23% reported that their physician recommended avoiding SHS. In contrast, more asthma participants recalled that their physicians inquired about SHS exposure (39.6%, although the difference was borderline significant p = 0.12) and recommended reducing SHS exposure (45.8%, p = 0.005)., Conclusion: Despite the increasing support for SHS exposure as a risk factor for CRS, relatively few physicians inquire about SHS and provide recommendations on SHS avoidance. Brief physician inquiry increases success of smoking cessation. Including SHS exposure in the medical history represents an opportunity for otolaryngologists to advise their patients about avoiding SHS and potentially alter disease outcomes., (© 2013 ARS-AAOA, LLC.)

Nasal crusting, rhinitis, and sinusitis are presentations of common conditions; however, these can also be the presenting symptoms of an underlying systemic disorder such as an infection, malignancy, or granulomatous disease. Granulomatous diseases with head and neck manifestations include Wegener's granulomatosis, Churg-Strauss syndrome, and sarcoidosis. These diseases are managed through a multidisciplinary approach that often includes otolaryngologists. This article presents a brief review of granulomatous diseases and their rhinologic manifestations and includes relevant diagnostic tests and systemic and local treatment options.

Background: Environmental factors such as inhaled pollutants like cigarette smoke may play a significant role in diseases of the upper airway including chronic rhinosinusitis (CRS). The objectives of this review are to summarize prior studies that describe the correlation between active smoking and secondhand smoke (SHS) on CRS. We also review the pathophysiologic effects of cigarette smoke on sinonasal mucosa and discuss its impact on surgical outcomes of endoscopic sinus surgery (ESS)., Methods: A literature search was conducted of the PubMed database using the terms "sinusitis" or "rhinosinusitis" and "smoking." Additional search terms of "nasal epithelial" and "smoke" were used to find articles that discussed pathophysiologic effects of tobacco smoke, whereas "secondhand smoke" was added to identify articles analyzing the correlation of SHS and CRS. Finally "endoscopic sinus surgery" and "outcomes" were linked to "smoking" to find articles that analyzed the impact of smoking on surgical results., Results: We identified 204 articles in the initial search. An additional 72 articles were reviewed for their relevance to the pathophysiologic effects of tobacco smoke while 31 articles were analyzed to determine the correlation of SHS and CRS. Twenty-nine articles were reviewed to analyze the impact of smoking on surgical results., Conclusion: There is clear evidence in the literature that cigarette smoke, either through active smoking or passive exposure to SHS, contributes to CRS. Recent prospective studies suggest that active smoking is not a contraindication to ESS, whereas the impact of smoking volume and long-term smoking after ESS has not been sufficiently evaluated., (Copyright © 2012 American Rhinologic Society-American Academy of Otolaryngic Allergy, LLC.)

Historically concurrent FESS/rhinoplasty was avoided due to concerns of increased risk of complication. Recent studies have shown that FESS/rhinoplasty can be performed simultaneously with good outcomes and no significant increase in complications. A thorough and effective approach to the patient with sinonasal obstruction requires attention to aesthetic, functional, and inflammatory issues. Medical treatment is an important adjuvant to surgery in order to optimize outcomes by improving patient symptoms long-term. Surgery for these patients should be performed in a careful, stepwise approach to address the nasal septum, inferior turbinates, paranasal sinuses, and external nasal structures., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Approximately 20% of the U.S. population suffers from allergic rhinitis (AR), and chronic rhinosinusitis (CRS) is estimated to affect 12.5% of the population. Frequently, many patients suffer from both disorders. In this study, we evaluated the relationship between AR and chronic rhinosinusitis as far as impact on nasal symptoms in a community-based case-control study of adult nonsmokers., Methods: In Washington County, MD, 200 subjects were recruited and interviewed from the same community. Subjects were divided into 4 study groups: AR without CRS, CRS without AR, AR with CRS, and a control group without AR or CRS. A validated questionnaire was used to assess upper respiratory symptoms, and disease-specific quality of life., Results: Upper respiratory symptoms were significantly more severe for the affected subjects when compared to controls. Symptom severity was greatest for the CRS groups with or without AR, followed by AR without CRS, and controls least symptomatic. Subjects with AR plus CRS were most likely to have had previous nasal surgery, and use nasal decongestants when compared to the other groups., Conclusion: While both AR and CRS are common in the United States, it appears that patients who suffer from both disorders have more severe symptoms and are more likely to have undergone nasal surgery than if they have only 1 of these disease states., (Copyright © 2011 American Rhinologic Society-American Academy of Otolaryngic Allergy, LLC.)

Background: Hepatocyte growth factor (HGF) is a growth factor thought to attenuate Th2-driven eosinophilic airway inflammatory responses. Increased expression of HGF and its receptor c-Met in nasal polyps suggests a role in disease pathogenesis. The effect of HGF on human sinonasal epithelial cell (SNEC) responses to Th2 inflammatory cytokines in chronic rhinosinusitis with nasal polyps (CRSwNP) has not been explored., Methods: SNECs isolated from patients with CRSwNP and control subjects were grown in cell culture at the air-liquid interface. The Th2 cytokine IL-13 was applied for 24 hours in the presence or absence of HGF. Eotaxin-3 and c-Met expression was assessed using real-time PCR, immunohistochemistry, and flow cytometry., Results: SNECs obtained from both CRSwNP and control subjects showed markedly increased expression of eotaxin-3 after exposure to IL-13. HGF significantly blocked IL-13-induced expression of eotaxin-3 in control SNECs, but not in SNECs derived from CRSwNP subjects., Conclusion: SNECs are active participants in sinonasal mucosal immunity, expressing inflammatory mediators in response to potential pathogens and endogenous cytokines. Although Th2 cytokines can elicit expression of proeosinophilic mediators by SNECs, HGF appears to have a down-regulating effect on this response. In patients with CRSwNP, SNECs are resistant to this attenuation, showing continued IL-13-induced eotaxin-3 expression despite HGF treatment. Abnormalities in the regulation of epithelial cell responses to endogenous cytokines and growth factors may contribute to the persistent eosinophilic inflammatory state in CRSwNP.

Background: The Accreditation Council for Graduate Medical Education requires that residency programs have an effective plan for assessing their residents' competence. Current evaluation tools used for the assessment of operative competency are subjective, recall based, and do not allow providing formative feedback to the resident. The purpose of this study was to evaluate the feasibility and validity of video-based assessment of endoscopic sinus surgery (ESS) skills., Methods: Five junior (postgraduate year levels 1-3[PGY-1 to -3]) and three senior (PGY-4 and -5) residents were videotaped as they performed ESS on cadavers in the laboratory. Five faculty members watched the recorded videotapes and rated performance using global and checklist assessment tools for ESS. Evaluators were blinded to the identity of the performers. Rating was made feasible by allowing the raters to fast-forward through the tapes when appropriate. Construct validity was calculated by comparing total scores and score on each item of the instrument across the training levels. For all statistical purposes p < 0.05 was considered significant., Results: Results showed construct validity with senior residents performing better than junior residents. It took an average of 20 minutes (range, 7- 39 minutes) to watch and evaluate a video. Interrater reliability, as measured by interclass correlation coefficient across evaluators, was 0.62., Conclusion: The use of videotapes combined with the objective assessment tool is a feasible and valid method for evaluating surgical skills. It has implications for residency programs, because it will increase faculty buy-in and reduce the potential for biased assessment.

Background: Abnormalities in host mucosal immunity exist in chronic rhinosinusitis with nasal polyps (CRSwNPs), but it is unclear whether this is a cause or an effect of the eosinophilic inflammation and frequent microbial colonization that characterizes the disease. Sinonasal epithelial cells (SNECs) are critical participants in healthy antimicrobial innate immune defense. They also can promote Th2 inflammation with various mediators, including interleukin (IL)-33, which induces T helper cells to produce Th2 cytokines., Methods: CRSwNP SNECs were obtained during sinus surgery and stored. Patients were subsequently classified as either treatment responsive or treatment recalcitrant, based on long-term outcomes of medical and surgical therapy. Epithelial cells from these patients were grown in air-liquid interface (ALI) culture and treated with IL-13, as well as the bacteria-associated molecule, CpG. Expression of IL-33 mRNA was determined by real-time polymerase chain reaction., Results: Recalcitrant CRSwNP epithelial cells had increased baseline expression of IL-33 compared with responsive CRSwNPs, which was further increased by 24-hour exposure to CpG. Treatment-responsive epithelial cells were not induced by CpG to express IL-33. Prolonged treatment with IL-13 during differentiation at the ALI diminished the baseline expression of IL-33 and prevented the subsequent induction of IL-33 by CpG., Conclusion: Mucosal innate immunity likely plays an important role in CRSwNP pathogenesis. A definitive link between infectious triggers and the development of Th2 inflammation has been elusive. We have found constitutive IL-33 expression by SNECs in recalcitrant CRSwNPs, which can be further induced by a bacteria-associated molecular pattern. Dysregulated epithelial cell immune interactions between host and environment may contribute to Th2 inflammation in CRSwNPs.

Background: Rhinosinusitis is a costly disease that adversely affects quality of life (QOL). It is known to be influenced by environmental factors, but few studies have evaluated the association between secondhand tobacco smoke (SHS) exposure and chronic rhinosinusitis (CRS). To address this evidence gap, we evaluated the association of SHS and CRS risk in a community-based case-control study of adult nonsmokers., Methods: In Washington County, MD, 100 cases with a confirmed diagnosis of CRS and 100 controls matched for age, sex, and smoking status (former-never) were recruited and interviewed. A validated questionnaire was used to assess past and present SHS exposure as well as disease-specific QOL., Results: Compared with those who reported no SHS exposure, current or childhood SHS exposure was associated with significantly increased risk of CRS (odds ratio, 2.33; 95% CI, 1.02, 5.34). CRS cases exposed to SHS (n = 39) had worse mean scores in nasal obstruction/blockage (3.1 versus 2.5; p = 0.02), nasal discharge (3.3 versus 2.7; p = 0.03), headaches (2.4 versus 1.5; p = 0.01), and cough (2.1 versus 1.5; p = 0.04) than cases without SHS exposure (n = 61). Cases exposed to SHS were also more likely to use nasal decongestants (53.9% versus 34.4%; p = 0.05)., Conclusion: Exposure to SHS during childhood and adulthood may be a risk factor for CRS. Furthermore, compared with unexposed CRS cases, SHS exposed cases reported worse nasal symptoms and used more nasal decongestants compared with unexposed cases, suggesting SHS exposure is related to exacerbation and more severe symptoms.

Objective: To explore surgical technique and outcomes of revision endoscopic sinus surgery (ESS) in patients with previously repaired cerebrospinal fluid (CSF) leaks., Design: A case series of 13 patients with previously repaired iatrogenic CSF leaks who underwent revision ESS for recurrent sinus disease; a review of the preoperative workup, intraoperative findings, and postoperative outcomes., Setting: Two academic medical centers., Patients: Patients were included if they had a history of previously repaired skull base defect and iatrogenic CSF leak in the vicinity of the planned revision ESS., Interventions: Revision ESS was performed in the vicinity of the previously repaired CSF leak. Dissection was carefully performed to avoid a recurrent CSF leak., Main Outcome Measures: Preoperative workup, intraoperative findings, surgical technique, and complications were reviewed., Results: The study population consisted of 7 men and 6 women. Surgical navigation was used for all cases. Intrathecal fluorescein was not used in any case. In no instances was an active preexisting CSF leak identified or a new leak created. No minor or major postoperative complications arose in any of the study patients. All patients were discharged home within 24 hours. The mean (SD) follow-up was 26.0 (16.7) months., Conclusions: Previous skull base injury with CSF leak is not a contraindication to revision ESS. Safe ESS in this setting can be performed and may be recommended to such patients with symptomatic recurrence of their sinus disease.

Objective: To identify genes whose expression is most characteristic of chronic rhinosinusitis and aspirin-sensitive asthma through genome-wide transcriptional profiling of nasal polyp tissue., Study Design: Prospective, controlled study conducted at a tertiary care institution., Methods: Thirty genome-wide expression microarrays were used to compare nasal polyp tissue from patients with chronic rhinosinusitis alone (CRS, n = 10) or chronic rhinosinusitis and a history of aspirin-sensitive asthma (ASA, n = 10) to normal sinonasal mucosa from patients who underwent surgery for non-sinus related conditions (controls, n = 10). Genes found to be most characteristic of each polyp phenotype, as determined from bioinformatic analyses, were validated using real-time quantitative polymerase chain reaction (RT-PCR) and immunohistochemistry in different patient sets., Results: The transcriptional signature of the control mucosa was distinctly different from that of either polyp phenotype. Genes most characteristic of the CRS phenotype included two upregulated genes--met proto-oncogene (MET) and protein phosphatase 1 regulatory subunit 9B (PPP1R9B)-and two downregulated genes--prolactin-induced protein (PIP) and zinc alpha2-glycoprotein (AZGP1). The gene most characteristic of the ASA phenotype was periostin (POSTN), which was upregulated relative to controls. Differences between the CRS and ASA phenotypes were associated with alterations in the 6p22, 22q13, and 1q23 chromosomal regions., Conclusions: Nasal polyps appear to have characteristic transcriptional signatures compared to normal sinonasal mucosa. The five genes identified in this study likely play roles in the pathogenesis of polyps associated with CRS and ASA, and are therefore attractive targets for novel medical therapies for these common debilitating diseases.

Background: As the population ages, the mean age of patients with chronic rhinosinusitis (CRS) likely will increase as will the frequency of endoscopic sinus surgery (ESS) in the older population. The purpose of this study was to compare symptom presentation, CT scores, endoscopy scores, and quality of life (QOL) measures in patients >60 years of age as compared with younger patients., Methods: A prospective cohort of 18 patients >60 years and 121 patients < or =60 years undergoing ESS for CRS were studied. Patient factors, symptom severity, and CT scores were examined preoperatively. Endoscopy and QOL scores were compared pre- and postoperatively between the two groups., Results: The prevalence of allergies, polyps, asthma, aspirin sensitivity, and revision surgery was similar in each age group. There was no statistically significant difference in the visual analog scale scores of symptom severity in each age group. Older patients had scores that were similar to younger patients with regard to CT (13.11 versus 11.63; p = 0.419), preoperative endoscopy (8.22 versus 7.96; p = 0.828), postoperative endoscopy (3.06 versus 4.82; p = 0.100), and change in endoscopy (-5.17 versus -3.15; p = 0.083). Older patients had similar preoperative, postoperative, and change scores when compared with younger patients on the Rhinosinusitis Disability Index (-15.33 versus -20.63; p = 0.318) and Chronic Sinusitis Survey (14.35 versus 23.11; p = 0.126)., Conclusion: Older patients with CRS present with symptoms and patient factors that are comparable with younger patients and have a similar degree of improvement on endoscopy scores and QOL measures after ESS.