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Background: Trial data demonstrate that mepolizumab, a humanized anti‐interleukin 5 monoclonal antibody, is effective for patients with severe asthma and comorbid chronic rhinosinusitis (CRS) with nasal polyps. This real‐world, retrospective cohort study investigated mepolizumab for US patients with severe asthma and CRS with/without sinus surgery. Methods: IQVIA PharMetrics Plus claims data from baseline and follow‐up (12 months before and after mepolizumab initiation) were used to analyze three patient cohorts: cohort 1 (severe asthma only); cohort 2 (severe asthma + comorbid CRS without sinus surgery); and cohort 3 (severe asthma+comorbid CRS+sinus surgery), allowing for cross‐cohort comparisons. Results: The analysis included 495, 370, and 85 patients in cohort 1, cohort 2, and cohort 3, respectively. Systemic and oral corticosteroid use was lower for all cohorts after mepolizumab initiation. In cohort 3, asthma rescue inhaler and antibiotic use were lower during follow‐up than baseline. Asthma exacerbations were reduced by 28% to 44% comparing follow‐up versus baseline, with the largest reduction in cohort 3 (ratio of incidence rate ratio [RR] vs cohort 1: 0.76; p = 0.036). Reductions in oral corticosteroid claims were greater following mepolizumab initiation for cohort 3 versus cohort 1 (RR, 0.72; p = 0.011) and cohort 2 (RR, 0.70; p < 0.01). In cohorts 1 through 3, outpatient and emergency department visits were reduced by 1 to 2 and 0.4 to 0.6 visits annually, asthma‐related and asthma exacerbation–related total costs were reduced by $387 to $2580 USD, and medical costs were reduced by $383 to $2438 USD during follow‐up. Conclusions: Consistent with trial data, mepolizumab use in real‐world practice shows benefits across comorbid patient cohorts with more a pronounced impact in those with severe asthma+comorbid CRS + sinus surgery. [ABSTRACT FROM AUTHOR]

Key Points: CRSwNP-specific mean total annual spending ranged from $5,837 (EDS-FLU) to $28,058 (dupilumab). Most CRSwNP patients receiving biologics had comorbid asthma and did not undergo sinus surgery. While biologics were covered by most Medicare Part D plans, only 37% of plans covered EDS-FLU., (© 2024 ARS‐AAOA, LLC.)

Background: Understanding patient-specific risk factors for complications of functional endoscopic sinus surgery (ESS) is critical. Previous work has investigated such risk factors, but a population-based analysis has not been performed to date. Objectives: This study analyzes the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database to identify patient-specific risk factors associated with complications following ESS. Methods: A retrospective cohort study of patients who underwent ESS was conducted using the NSQIP database from 2011 to 2017. Patients were identified using CPT-codes for ESS procedures. The primary outcome analyzed was any postoperative complication. Simultaneous procedures with ESS were controlled for with regression analysis. Post-operative complications and 30-day readmission were evaluated using multivariate logistic regression controlling for age, gender, race, comorbidities (diabetes mellitus, hypertension, chronic obstructive pulmonary disease, congestive heart failure, renal failure, steroid use, and cancer history), smoking history, and intraoperative factors. Results: A total of 1279 patients who underwent ESS were identified. The average age of patients was 46.1 (SD = 16.8). Most patients (58.2%) had no major comorbidities. 594 (46.4%) patients had a tonsillectomy, adenoidectomy, or uvulopharyngoplasty at the same time as ESS. 101 (7.9%) patients experienced a complication post-operatively. 46 (3.6%) patients experienced a readmission postoperatively. The most common complication was reoperation (N = 40, 3.1%). Regression analysis revealed that gender was the only demographic factor associated with risk of post-operative complications, with women having a significantly lower risk than men (OR = 0.61, 95% CI 0.37-0.99, P =.046). Conclusions: ESS is typically performed on a relatively young and healthy population. Women have a significantly lower risk of complications after controlling for comorbidities. Further analysis of gender-specific differences in surgical outcomes should be evaluated to understand this phenomenon. [ABSTRACT FROM AUTHOR]

Background: Medical malpractice occurs when a hospital or health-care provider through negligent act or omission results in an injury to a patient. More than 50% of otolaryngologists have faced at least 1 claim, with rhinology being the most litigated subspecialty. This study aims to analyze medical litigation trends in Rhinology from 2000 to 2017 in the United States. Methods: The Westlaw database was reviewed from 2000 to 2017. Data were compiled on the demographics of the plaintiffs, procedures, nature of damages, legal allegations, and the use of expert witnesses, physician demographics/practice characteristics, verdicts, indemnities, and county/state of case. Results: There were 75 cases that met inclusion criteria after review of 125 cases. Majority of cases went to trial over settlement (80%) and were found in the Northeast region of the United States (36%). Most common cited legal allegations were improper performance and failure to follow standard of care. The most common nature of injuries were eye injury (29%) and intracranial complications (27%). The highest payouts were for progression of disease followed by intracranial injury. Of the 75 total cases analyzed, 37 (49.3%) used expert witnesses. When an expert witness was used at trial, the verdict statistically favored the defendant (62.5%). Conclusions: Our analysis reveals the importance of meticulous surgical techniques and thorough preoperative evaluations. [ABSTRACT FROM AUTHOR]

Background Over the past decade, the use of balloon sinuplasty has increased widely in the United States. Since its introduction, no nationally representative, population-based study has examined its use among chronic rhinosinusitis (CRS) patients. Methods We conducted a retrospective cohort study of patients diagnosed with CRS between 2011 and 2014, and compared the prevalence of conventional functional endoscopic sinus surgery (FESS), balloon sinuplasty, and hybrid sinus surgery according to surgical site and calendar year. Results Out of 11 million to 11.4 million enrollees per year, a total of 661,738 patients with the diagnosis of CRS were included in the analyses. There was an increase in the use of balloon sinuplasty as a stand-alone procedure from 5% in 2011 to 22.5% in 2014. Conventional FESS continued to be the most commonly performed sinus procedure over the study period. Multinomial logistic regression analyses showed a linear increase in balloon sinuplasty and hybrid procedures from 2011 to 2014. Compared to patients over 60 years, patients younger than 30 years had lower odds of having a balloon sinuplasty as a stand-alone procedure compared to FESS. Compared to patients in the West, patients in the South, Northeast, and Midwest were significantly more likely to have balloon sinuplasty as a stand-alone procedure. Assessment of the sinus surgery site showed that patients with additional frontal sinus surgery were more likely to have a balloon-only procedure (odds ratio [OR], 4.67; 95% confidence interval [CI], 4.21 to 5.17) or a hybrid procedure (OR, 8.69; 95% CI, 7.48 to 10.11) than conventional FESS when compared to patients with conventional maxillary surgery only. Conclusion From 2011 to 2014 there was an increase in the use of balloon sinuplasty and a modest decrease in the use of conventional FESS in the United States. Patients with frontal or sphenoid sinus surgical sites were more likely to have a balloon or hybrid procedure. [ABSTRACT FROM AUTHOR]

Objective: The utilization of image-guided navigation during endoscopic sinus surgery (ESS) has increased significantly since its introduction. However, the most common associated complications are still unknown. This study describes and analyzes adverse events related to image-guided ESS., Study Design: Cross-sectional analysis., Setting: The Food and Drug Administration's 2018-2022 MAUDE database (Manufacturer and User Facility Device Experience)., Methods: The MAUDE database was searched for all reports on adverse events involving sinus navigation systems used in ESS from 2018 to 2022. Reported events were reviewed and categorized., Results: During the study period, there were 1857 adverse events from 1565 reports, which were divided into device-related (n = 1834, 98.8%) and patient-related (n = 23, 1.2%) complications. The most common device-related complications were nonfunctionality of the system (n = 512, 27.9%), device imprecision (n = 427, 23.3%), and device sensing problems (n = 277, 15.1%). The most common patient-related complications were cerebrospinal fluid (CSF) leak (n = 14, 60.9%), intracranial injury (n = 4, 17.4%), and bleeding/hemorrhage (n = 3, 13.1%). Imprecision was associated with increased risk of navigation abortion by the surgeon (odds ratio, 1.50 [95% CI, 1.38-1.65]; P < .001) and increased risk of CSF leak (odds ratio, 16.5 [95% CI, 3.66-74.0]; P < .001) as compared with other device-related complications., Conclusions: The most commonly reported device- and patient-related adverse events associated with image-guided sinus navigation systems were device nonfunction, imprecision, device sensing difficulties, and CSF leak. When imprecise navigation occurred, there was an increased likelihood of CSF leak and navigation abortion by the surgeon. Health care providers should be mindful of these possible complications when electing to use image-guided sinus navigation during ESS., (© 2022 American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

Purpose: Endoscopic sinus surgery for patients with chronic rhinosinusitis (CRS) unresponsive to medical therapy has traditionally been performed under general anesthesia and in the operating room. Balloons for catheter dilation of paranasal sinuses were introduced in 2005, allowing sinus surgery to be safely performed either in the operating room or the office care setting, under local anesthesia. This change in care setting has raised concerns of overuse or expanded indications for sinus surgery. This study was thus designed to evaluate changes in surgical volumes in the United States, for the period 2006-2011, and to evaluate the impact of the sinus balloons on surgical practice. Methods: The MarketScan® Commercial Claims and Encounter Database was queried for the period 2006 to 2011 using CRS International Classification of Diseases, Ninth Revision codes (473.X) and sinus surgery US-based Common Procedural Terminology (CPT) codes (endoscopic sinus surgery: CPT codes 31254-31294 and 31299; balloon catheter dilation: CPT codes 31295-31297). MarketScan's projection methodology was applied to estimate the nationwide prevalence of CRS and the incidence of sinus surgery. Procedural case mix and total average payment per surgery were analyzed. Results: From 2006 to 2011, the yearly prevalence of CRS and sinus surgery volume remained flat with ~430 patients with CRS per 100,000 in the employer-sponsored insured population, of which ~117/100,000 underwent surgery. In 2006, 2.69 paranasal sinuses (95% confidence interval [95% CI]: 2.65-2.71) were treated during each individual sinus surgery, with an additional 1.11 nasal procedures (95% CI: 1.08-1.13) performed concurrently. By 2011, the procedural case mix had expanded to 2.90 sinus (95% CI: 2.87-2.93) and 1.16 nasal procedures (95% CI: 1.14-1.85) per surgery. Payments increased from $7,011.06 (α=$6,378.30; β=3.1490) in 2006 to $9,090.11 (α=$8,350.20; β=2.9535) in 2011, in line with US medical inflation. Conclusion: In the study population, approximately 1 in 3.7 patients diagnosed with CRS underwent sinus surgery. This ratio remained constant from 2006 to 2011. There was no evidence that the number of distinct sinus surgeries per 100,000 people increased despite the introduction and utilization of balloon catheter dilation tools that enabled migration of sinus surgery to the office. [ABSTRACT FROM AUTHOR]

Background Patients with refractory chronic rhinosinusitis (RCRS) have persistent symptoms despite best medical therapy. Some evidence suggests continued medical therapy (CMT) is appropriate for patients with RCRS. The primary objective of this study was to evaluate the clinical impact of CMT in patients with RCRS who have significant reductions in baseline disease-specific quality of life (QoL) and would be considered candidates for endoscopic sinus surgery (ESS). Methods A prospective longitudinal observational study was undertaken between August 2011 and June 2013. Inclusion criteria: age >18 years, CRS defined by American Academy of Otolaryngology (AAO) adult sinusitis guidelines, failed medical therapy (defined by a 3-month minimum of topical intranasal steroid, minimum 7-day course of systemic corticosteroid, ± 2-week course of broad spectrum systemic antibiotic), and elected ESS. Primary outcomes were change in disease-specific QoL and endoscopic scores between enrolment and immediately prior to ESS. Secondary outcomes included medication consumption and work days missed. Results A total of 31 patients were enrolled. Following CMT for a mean of 7.1 months, there was an absolute worsening in mean 22-item Sino-Nasal Outcomes Test (SNOT-22) score between baseline and preoperative follow-up, 57.6 to 66.1, respectively ( p = 0.006). There was a significant worsening of mean endoscopic score between baseline and preoperative follow-up, 6.9 to 7.7, respectively ( p = 0.002). There was an increase in budesonide irrigations along with a reduction in use of topical nasal steroid sprays prior to ESS. Patients experienced a mean increase of 3.6 work days lost while receiving CMT ( p = 0.023). Conclusion Results from this study suggest that patients with RCRS who have significant reductions in baseline disease-specific QoL do not experience clinical improvement while receiving CMT. [ABSTRACT FROM AUTHOR]

Objective: Balloon sinuplasty (BSP) is associated with varied practice patterns. This study sought to identify otolaryngologist characteristics associated with BSP utilization., Study Design: Retrospective analysis of Medicare claims data and the National Physician Compare database., Methods: Outlier otolaryngologists were compared to non-outliers. Otolaryngologist characteristics included sex, practice size, geographic setting, years of experience, procedure setting, 10 or fewer endoscopic sinus surgeries per year for 3 or more years, and high number of services per unique Medicare beneficiary. Outlier status was defined as performing an annual total of balloon procedures of 2 standard deviations (SDs) above the mean for all otolaryngologists in the same year., Results: Between January 2012 and December 2017, 1,408 otolaryngologists performed 101,662 endoscopic sinus surgeries and 97,680 BSP procedures. Sixty-six outlier otolaryngologists (4.7%) accounted for 44.3% of all BSP procedures. Outlier status was associated with practice size of 10 or fewer individual providers (OR, 5.15; 95% CI, 2.73-9.74; P < .001), performance of 10 or fewer total endoscopic sinus surgeries per year for 3 or more years (OR, 3.90; 95% CI, 1.59-9.57; P = .003), and high number of overall services per beneficiary (OR 6.70; 95% CI, 1.19-37.84; P = .031). Provider sex, years of experience, and geographic setting were not associated with outlier status., Conclusion: Outlier BSP patterns are associated with a few otolaryngologists who are more likely to be identified in small practices and record low numbers of endoscopic surgeries. Although BSP is an appropriate and effective tool, identification of outlier patterns may help to facilitate peer-to-peer counsel., Level of Evidence: 3 Laryngoscope, 132:1340-1345, 2022., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

The goal of this American Rhinologic Society expert practice statement (EPS) is to provide clinically applicable, evidence-based recommendations regarding pain management in sinonasal surgery. This EPS was developed following the recommended methodology and approval process as previously outlined. The topics of interest included preoperative counseling, local anesthesia, use of opioids for postoperative pain, use of nonopioid medication for postoperative pain, nonsteroidal anti-inflammatory drugs and bleeding, and use of gabapentin for pain control. Following a modified Delphi approach, 6 statements were developed, 5 of which reached consensus and 1 that did not. These statements and accompanying evidence are summarized along with an assessment of future needs., (© 2021 ARS-AAOA, LLC.)

Introduction: The pandemic caused by the novel coronavirus virus has altered all facets of clinical practice in the United States. The goal of this study is to better understand the impact of COVID-19 on rhinologic ambulatory and operative practice., Methods: A 27-item survey to assess these objectives was created and approved by the Division of Rhinology faculty at Rush University Medical Center in April 2020. The survey was then distributed to rhinologists in a web based format via www.surveymonkey.com from April 10 through April 23, 2020., Results: A total of 277 U.S based rhinologists responded to the survey (23.04%). The most common practice types were single specialty private (44.9%) and academic (24.6%). 90.2% practice in a state under a shelter in place order. Comparing pre-COVID baseline to during-COVID, there was statistically significant reduction in the number of patients of seen daily in clinic ( p  < 0.001). The number of nasal endoscopies in the office and surgical procedures fell dramatically. Overall, 5 respondent rhinologists have been infected with COVID-19 and 27 have been furloughed., Conclusion: COVID-19 has drastically affected rhinologic practice. There is a dramatic reduction of in person care in the office setting and surgical management of sinonasal and skull base disease. Enhanced PPE is being used in only half of potentially aerosolizing procedures which represents an area of further education. Novel approaches such as use of virtual encounters and point of care testing should be considered as options to facilitate care.

Objectives/hypothesis: To quantify and analyze the concurrent performance of rhinoplasty (RP) (with or without septoplasty) and functional endoscopic sinus surgery (FESS)., Study Design: Cross-sectional analysis., Methods: Current Procedural Terminology codes were used to extract cases of RP (n = 22,360), FESS (n = 99,173), and concurrent RP with FESS (RP + FESS) (n = 1,321) within the State Ambulatory Surgery Databases of California, Florida, Maryland, and New York from 2009 to 2011. Patient demographics, surgeon volume, charge, concurrent nasal procedures, and operating room (OR) time were compared., Results: Among the 1,321 RP + FESS combination cases, a majority involved primary rhinoplasty (n = 697, 52.8%), followed by nasal valve repair (n = 563, 42.6%) and revision rhinoplasty (n = 61, 4.6%). High-volume (n > 30), medium-volume (n = 10-30), and low-volume rhinoplasty surgeons (n ≤ 9) were observed to perform a similar number of FESS + RP combination surgeries (153, 152, and 155, respectively). A majority of RP + FESS involved two or fewer sinuses (65%). Mean OR time for RP + FESS was 189.4 ± 4.2 minutes, approximately 50 minutes shorter than the sum of standalone RP performed individually (138.8 ± 1.0 minutes) and standalone FESS (102.9 ± 0.4 minutes)., Conclusions: RP + FESS more frequently involved fewer sinuses (compared with FESS alone) and was also less likely to involve revision rhinoplasty (compared with rhinoplasty alone); therefore, these cases may be selected for lower sinus disease burden and less complex rhinoplasty compared to standalone procedures. Procedures combining rhinoplasty and sinus surgery had a reduction in OR time compared to the hypothetical sum of two standalone procedures., Level of Evidence: NA Laryngoscope, 130:E311-E319, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Balloon sinuplasty utilization has increased significantly since its introduction over a decade ago. However, the most common associated complications are still unknown. The objective of this study was to analyze adverse events related to balloon sinuplasty., Study Design: Retrospective cross-sectional analysis., Setting: Food and Drug Administration's MAUDE database (Manufacturer and User Facility Device Experience; 2008-2018)., Subjects and Methods: The MAUDE database was searched for all reports on adverse events involving balloon sinuplasty devices from the 3 leading manufacturers: Acclarent, Entellus, and Medtronic. Reported events were reviewed and categorized., Results: During the study period, there were 211 adverse events from 208 reports divided into the following categories: patient related (n = 102, 48.3%), device related (n = 101, 47.9%), and packaging related (n = 8, 3.8%). Four periprocedural deaths were reported but were not clearly associated with technical complications. The most common device-related complications were guide catheter malfunction (39.6%), balloon malfunction (38.6%), and imprecise navigation (17.8%). The most common patient-related complications were cerebrospinal fluid leak (36.3%), eye swelling (29.4%), and epistaxis (11.8%). A lateral canthotomy was performed in 30.0% of eye-swelling complications. Sixty percent of eye complications occurred during balloon dilation of the maxillary sinus. The years 2014 (n = 48) and 2012 (n = 32) had the highest number of adverse events reported as compared with all other years., Conclusion: The most common adverse events associated with balloon sinuplasty include balloon malfunction, guide catheter malfunction, cerebrospinal fluid leak, and significant eye swelling. Health care providers should discuss these possible complications when consenting patients for balloon sinuplasty.

Objectives/hypothesis: Balloon sinuplasty has become an increasingly popular option for patients undergoing surgical treatment of sinusitis. This study analyzes utilization and growth of these procedures across a large cohort of patients over a 5-year period., Study Design: Retrospective data review., Methods: This was a retrospective review of Medicare utilization and billing data. Utilization and payment values were obtained from Medicare claims data using Centers for Medicare and Medicaid Services datasets. All Medicare claims were analyzed from 2012 to 2016. Data were extracted for balloon sinuplasty and endoscopic sinus surgery claims. Procedure location, total submitted claims, charges, and payments were compared., Results: From 2012 to 2016, the number of balloon procedures increased from 5,603 to 25,640. Traditional endoscopic sinus surgery procedures increased from 15,509 to 18,164. Aggregate Medicare payments to otolaryngologists for endoscopic sinus surgery have remained relatively stable, whereas there has been a 450% increase in total payments to providers of balloon sinuplasty. In 2016, total payments to providers of balloon procedures ($40.5 million) were substantially higher than payments to providers of non-balloon-based endoscopic sinus surgery ($4.7 million). The number of providers performing balloon procedures has increased 277% versus 17% for traditional sinus surgery., Conclusions: There has been a rapid expansion in the number of sinus procedures in the Medicare population from 2012 to 2016. Office-based balloon procedures account for the overwhelming majority of the increases in procedures and payments. Per procedure and aggregate payments are now higher for sinuplasty procedures than for traditional sinus surgery., Level of Evidence: NA Laryngoscope, 129:2224-2229, 2019., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Opioid-related deaths in the United States have increased 200% since 2000, in part due to prescription diversion from patients who had a surgical procedure. The purpose of this study was to characterize provider prescription patterns and assess patient-reported opioid use after endoscopic sinus surgery (ESS)., Study Design: Retrospective chart review., Methods: Patients who underwent ESS between May 2017 and May 2018 were included. Opioid prescription, operative details, and postoperative opioid use data were extracted. The Massachusetts Prescription Awareness Tool (MassPAT) was queried to determine if patients filled their prescription., Results: One hundred fifty-five patients were included. Nearly all patients received an opioid prescription (94.8%). An average of 15.6 tablets was prescribed per patient. Among 116 patients with MassPAT data, 91.4% filled their prescription. Among 67 patients who reported the number of tablets they had used at the time of first follow-up appointment, 73.1% reported taking no opioids. Mean number of tablets prescribed was significantly greater among patients who underwent primary versus revision surgery (16.5 vs. 13.5, P = .0111) and those who had splints placed (21.5 vs. 15.1, P = .0037). Predictors of opioid use included concurrent turbinate reduction (58.3% vs. 14.3%, P < .0001) and concurrent septoplasty (45.5% vs. 21.6%, P = .039)., Conclusions: Nearly all patients who underwent ESS were prescribed an opioid, and nearly all patients filled their prescription. However, the vast majority of patients did not require any opioid medication for postoperative pain control. As the opioid epidemic continues to persist, these findings have immediate relevance to current prescribing patterns and pain management practices., Level of Evidence: 4 Laryngoscope, 129:1046-1052, 2019., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Understanding the variation in costs of endoscopic sinus surgery (ESS) is critical to defining value. Current published costs of ESS have not identified potential sources of variation. Our objective was to analyze ESS costs to identify sources of variance that could guide value-improving decisions., Methods: ESS cases (n = 1739) performed between 2008 and 2016 were identified from a database of 22 rural to tertiary facilities. Cost and time data were extracted from the database. Medical records were reviewed to confirm procedures. Three bilateral groupings were examined (n = 895 cases from 13 facilities): (1) full ESS (all sinuses); (2) intermediate ESS (total ethmoid, maxillary); and (3) anterior ESS (anterior ethmoid, maxillary). Cost and operative time were analyzed using multivariable gamma regression., Results: Median costs for full, intermediate, and anterior ESS were $4281, $3716, and $2549 U.S. dollars (p < 0.001). Median durations were 87, 60, and 58 minutes (p < 0.001). Among patients with no additional procedures, those with full ESS had operative duration, total cost, and supply costs that were 1.37 (95% confidence interval [CI], 1.17 to 1.61), 1.52 (95% CI, 1.32 to 1.75), and 2.40 (95% CI, 1.76 to 3.25) times greater than anterior ESS, respectively (all p < 0.001). Intermediate ESS duration at community urban facilities was 1.87 (95% CI, 1.74 to 2.02) times that of community rural facilities (p < 0.001)., Conclusion: Duration of surgery, extent of surgery, and location of surgery are sources of significant variation in the cost of ESS. These findings will assist healthcare policy makers, hospitals, and surgeons in optimizing the value of ESS., (© 2018 ARS-AAOA, LLC.)

Objectives:: Pediatric sinus surgery is indicated for a wide range of sinonasal and skull base pathologies, but it is most commonly performed for recalcitrant chronic rhinosinusitis or complicated acute sinusitis. The authors aim to report medical risk factors of morbidity and mortality following inpatient sinus surgery in the pediatric population., Methods:: Using data from the Kids' Inpatient Database from 2003 to 2012, patients with International Classification of Diseases, Ninth Revision, procedure codes for primary sinus surgery were identified. Mixed-effect multivariable logistic regression was used to identify risk factors of inpatient postoperative morbidity and mortality., Results:: The final sample included a weighted estimate of 4965 pediatric patients. The rates of inpatient morbidity and mortality were 6% and 1%, respectively. Respiratory complications (2.5%) were the most prevalent postoperative adverse events. The most prevalent comorbidities were chronic sinusitis (59.8%), acute sinusitis (27.8%), and cystic fibrosis (26.4%). Compared with patients who did not experience any morbidity, patients with inpatient morbidity had higher rates of pneumonia, mycoses, and nasal or paranasal benign neoplasm ( P < .05). The odds of inpatient morbidity and mortality were highest for patients with leukemia (odds ratio, 2.74; 95% confidence interval, 1.59-4.72; P < .001) and mycoses (odds ratio, 15.84; 95% confidence interval, 6.45-38.89; P < .001), respectively., Conclusions:: This study is the first to report the national comorbidity burden and risk factors for postoperative adverse events following inpatient sinus surgery. Knowledge of the comorbidities and independent factors associated with morbidity and mortality will help in directing preoperative optimization and counseling., Level of Evidence:: 2c.

Background: Quality improvement (QI) in the management of chronic rhinosinusitis (CRS) is garnering increasing attention. Defining frameworks and metrics to assess the quality of key components in CRS management could assist in reducing unwarranted practice variation and increase high-quality care., Methods: A panel of the American Rhinologic Society (ARS) QI committee reviewed the literature to determine important presurgical components of CRS care that warrant QI. The evidence was organized into 4 categories: (1) diagnosis, (2) medical management, (3) appropriate patient selection for surgery, and (4) patient-centered discussion. The combination of these categories was used to develop a framework termed the CRS Appropriate Presurgical Algorithm (CAPA)., Results: Prior to offering surgery for CRS, the best available evidence support the following quality metrics: (1) a guideline-based diagnosis should be confirmed; (2) appropriate medical management, including a minimum of topical corticosteroid therapy and saline irrigations, should have been attempted (assuming patient tolerance); (3) a computed tomography (CT) scan should be obtained (to confirm the presence of sinus inflammation and for surgical planning); and (4) a patient-centered discussion regarding treatment options for refractory CRS (ie, alternative medical therapies vs surgery vs observation) while focusing on risks and benefits, the need for long-term medical compliance, and understanding of patient preferences and expectations., Conclusion: Defining metrics that assess key components to CRS care prior to offering surgery has the potential to further improve upon an already successful treatment paradigm, reduce unwarranted practice variation, and to ensure that patients are receiving a similar level of high-quality care., (© 2018 ARS-AAOA, LLC.)

Background Since the Food and Drug Administration approval of balloon sinuplasty (BSP) in 2005, no nationally representative population-based studies have examined the outcomes and adverse events of BSP. Objective To assess the rates of complications and revision surgery in patients who received BSP, functional endoscopic sinus surgery (FESS), or a hybrid procedure. Methods Using one of the nation's largest commercial insurance databases, we conducted a retrospective cohort study of pediatric and adult patients diagnosed with chronic rhinosinusitis between 2011 and 2014 who underwent BSP, conventional FESS, or a hybrid procedure. The primary outcomes were surgical complication and revision rates within 6 months of initial surgery. Results A total of 16,040 patients who underwent sinus surgery were included. Overall, 2,851 patients underwent BSP, 11,955 underwent conventional FESS, and 1 234 underwent a hybrid procedure. BSP surgery was more likely to have been performed in an office setting (86.53%) compared to FESS (0.74%). The complication rate was 5.26% for BSP and 7.35% for conventional FESS. Revision rates were 7.89% for BSP, 16.85% for FESS, and 15.15% for a hybrid procedure. Conclusion Despite the low overall risk, major complications occur with BSP including cerebrospinal fluid leak, pneumocephalus, orbital complications, and severe bleeding. Otolaryngologists should discuss these risks with their patients. Prospective studies are still needed to compare outcomes of BSP with those of FESS.

Objectives/hypothesis: Ethmoidectomy may be sufficient to address frontal sinus disease, but some surgeons may perform frontal recess dissection initially. Our objectives were to describe patient-associated factors with frequency of frontal sinus surgery and analyze the association with provider volume., Study Design: Retrospective cohort analysis., Methods: The 2013 State Ambulatory Surgery Databases of New Jersey, Florida, and Kentucky were queried to identify adults who underwent anterior ethmoidectomy or total ethmoidectomy using standard Current Procedural Terminology codes. Univariate and multivariate logistic regression was performed to determine the odds of undergoing concurrent frontal sinus exploration along with ethmoidectomy, adjusting for age, gender, race, insurance type, median income, and the metropolitan designation by zip code. We also examined provider and center volume, use of image guidance, and total charges., Results: There were 10,564 ethmoidectomies, of which 4,726 had concurrent frontal sinus surgery. Women were less likely to have frontal sinus surgery (P = .0011), as were patients with Medicare (P = .007). Hispanics were more likely to have frontal sinus surgery (P = .0003). Surgeons with higher surgical volumes were more likely to perform frontal sinus surgery; it was also more likely to be performed in centers where more sinus procedures occurred (P < .0001, both)., Conclusions: Variation in the utilization of frontal sinus surgery is associated with patient sex, ethnicity, insurance status, geography, as well as provider and hospital volumes. These data support the idea that nonclinical factors may influence the treatment of frontal sinus disease., Level of Evidence: 4. Laryngoscope, 128:2008-2014, 2018., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: (1) Become familiar with reported adverse events related to balloon dilation of the paranasal sinus ostia. (2) Understand the sequelae occurring with these events., Study Design: Retrospective analysis of a prospective database., Setting: OpenFDA database., Subjects and Methods: The OpenFDA program website of the Food and Drug Administration was queried with the Application Program Interface query system for medical device adverse events involving balloon devices for the dilation of paranasal sinus ostia from January 2006 through December 2014. The raw data were then tabulated, with adverse events codified by event type, sinus involved, injury type, device malfunction, surgeon error, and qualitative data. Sequelae were also quantified., Results: In sum, 114 adverse events were identified. Patient injury was the most frequently reported adverse event (n = 72), followed by 36 device malfunctions, 4 deaths, and 2 unclassified. The most common injury involved orbital complications, including 23 (20.2%) orbital wall fractures and 22 (19.3%) postseptal and 22 (19.3%) preseptal orbital injuries. In addition, there were 17 (14.9%) skull base injuries and 7 (6.1%) cases of severe epistaxis observed; 11 (9.6%) cases mentioned surgeon error. Cerebrospinal fluid leak was significantly associated with frontal surgery (P = .002) and sphenoid surgery (P = .001), whereas post- and preseptal orbital injury was associated with maxillary surgery (P = .017 and P = .002). Epistaxis was associated with sphenoid surgery (P = .032)., Conclusions: Based on the number of balloon sinus procedures performed, Food and Drug Administration-reported adverse events are uncommon, although a select portion can be severe. Surgeons should be aware of different complications reported with specific sinuses addressed with balloon techniques., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.)

Objectives/hypothesis: The primary objective of this pilot study was to define the change in productivity costs following endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS). Secondary objectives were to identify CRS-related characteristics that may influence the degree of productivity improvement after ESS., Study Design: Prospective, multi-institutional, observational cohort study., Methods: The human capital approach was used to define productivity costs. Annual absenteeism, presenteeism, and lost leisure time were quantified to define annual lost productive time (LPT). LPT was monetized using the annual daily wage rates obtained from the 2012 US Census and the 2013 US Department of Labor statistics., Results: Twenty-seven patients with refractory CRS who underwent ESS were followed for a mean of 15 months (range, 8-25 months). Following ESS, there were improvements in annual absenteeism (22 days reduced to 3 days), annual presenteeism (41 days reduced to 19 days), and annual household days lost (12 days reduced to 6 days). Overall, the preoperative productivity costs were reduced after ESS ($9,190 vs. $3,373, respectively; P < .001)., Conclusions: Daily productivity is negatively impacted by the presence of CRS. The outcomes from this study provide the first insights into the reduced productivity costs associated with receiving ESS for refractory CRS. Future studies with larger sample sizes will need to validate the results from this pilot study., Level of Evidence: 2c Laryngoscope, 126:570-574, 2016., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Sinonasal disease is a common condition treated by otolaryngologists. Malpractice in this area is the most common litigation faced by otolaryngologists. This study analyzes malpractice in the treatment of sinonasal disease., Study Design: Case series, review of legal records., Setting: Legal databases., Subjects and Methods: Using 2 different computerized legal databases, the phrase medical malpractice was searched with terms related to sinonasal disease involving court cases in the past 10 years (2004-2013), yielding 26 cases. The cases were analyzed for pertinent data regarding plaintiffs, presenting complaint, practice setting, type of malpractice, resulting injury, result of verdict, and amount of reward or settlement., Results: Chronic sinusitis (42%) was the most common presenting symptom. Many cases included multiple types of alleged malpractice, with the most common being negligent technique (38%) and lack of informed consent (27%). The most common alleged injuries included cerebrospinal fluid leak, meningitis, nasal obstruction, and orbital trauma. Defendants prevailed in 13 of 18 cases in which outcomes were known, with mean award of $225,000 and mean settlement of $212,500. The cases won by plaintiffs were all in a private practice setting., Conclusion: Otolaryngologists should be aware of the causes of malpractice litigation as it relates to treatment of sinonasal disease. Lack of informed consent continues to be a common allegation, and surgeons should ensure complete informed consent is obtained and well documented. A unified and complete database of medical malpractice cases is needed to allow for further analysis of specialty-related claims., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015.)