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Objectives/Hypothesis To determine patient recall of specific risks associated with endoscopic sinus surgery and whether an adjunct multimedia education module is an effective patient tool in enhancing the standard informed consent process. Study Design Prospective, randomized, controlled trial. Methods Fifty consecutive adult patients scheduled for endoscopic sinus surgery at a rhinology clinic of a tertiary care hospital were recruited for this study. Informed consent was studied by comparing the number of risks recalled when patients had a verbal discussion in conjunction with a 6-minute interactive module or the verbal discussion alone. Early recall was measured immediately following the informed consent process, and delayed recall was measured 3 to 4 weeks after patient preference details were also collected. Results Early risk recall in the multimedia group was significantly higher than the control group (P = .0036); however, there was no difference between the groups in delayed risk recall. Seventy-six percent of participants expressed interest in viewing the multimedia module if available online between the preoperative and procedural day. Sixty-eight percent of patients preferred having the multimedia module as an adjunct to the informed consent process as opposed to the multimedia consent process alone. Conclusions There is an early improvement in overall risk recall in patients who complete an interactive multimedia module, with a clear patient preference for this method. Here we emphasize the well-known challenges of patient education and demonstrate the effectiveness of integrating technology into clinical practice in order to enhance the informed consent process. Level of Evidence 1b Laryngoscope, 126:1273–1278, 2016

Objectives/Hypothesis To illustrate the reliability of the Pang-Rotenberg (PR) sign as a prognosticator of snoring surgery. Our hypothesis was that patients who are PR-positive have better snoring reduction scores and outcomes than PR-negative patients after nose and palate surgery. Study Design A multicenter prospective series of 153 patients with snoring. Methods All patients graded the snoring intensity on a visual analog scale (VAS). All 137 patients enrolled had both the nose surgery and palate surgery. The control group consisted of 16 patients who underwent nasal surgery alone. Results There were 122 men and 15 women, the mean age was 44.6 years old, and mean body mass index was 26.1. There were 15 simple snorers and 122 obstructive sleep apnea patients. Patients who were PR-positive showed significantly better postoperative snoring VAS reduction (from 9.04 to 1.02) compared to those patients who were PR-negative (from 8.91 to 3.14) (P

Objective This study examines the rate of occult malignancy in routine histopathological analysis of tonsillectomy specimens from benign surgical cases in adults. Study Design Retrospective data review. Methods 181 consecutive charts of tonsillectomies performed for benign indications between March 2007 and March 2014 were reviewed. Data on age, indications for surgery, preoperative and intraoperative clinical findings, and final pathology results were collected. A literature review of studies examining the rate of occult malignancy in tonsillectomy specimens was also performed, and the combined data was pooled. The financial impact of routine tonsil pathological analysis was determined. Results In 181 patients, there was one case of occult malignancy. After study inclusion and exclusion criteria were met, a review of the literature yielded 3,724 pooled tonsillectomy cases, with no case of unsuspected occult malignancy reported in the literature. The number needed to screen combining our series with the reported literature was 3,904. The financial impact of routine histopathological analysis at our institution was determined to be CAD $3308 per year. Conclusion Routine pathological analysis of tonsil specimens recovered from surgery performed for benign indications, in the absence of any suspicion preoperatively for malignancy, is not supported by current evidence and is not financially sound. Modern evidence does not support the need for even gross specimen analysis in these cases. Level of Evidence 4. Laryngoscope, 125:1595–1599, 2015

Background Functional endoscopic sinus surgery (FESS) is standard for patients who fail medical management of chronic sinusitis (CRS). The beneficial impact of surgery on CRS is well known. However, patients often note that their sleep is improved after FESS even without simultaneous correction of nasal obstruction. Sleep outcomes after FESS are significantly understudied. Hence in the current study we look to characterize patient sleep quality following sinus surgery. Methods Data was gathered from 2 sites (Western University [Canada] and the Asia Sleep Center [Singapore]). Patients meeting diagnostic criteria for CRS without nasal polyposis (CRSsNP) were included. Cases with polyposis and those who needed a septoplasty were excluded so as to purely analyze the impact of the sinus surgery on sleep. Sleep outcomes recorded at baseline just prior to surgery and 6 months after surgery were the Epworth Sleepiness Scale (EpSS) and the Pittsburgh Sleep Quality Index (PSQI). We also recorded 22-item Sino-Nasal Outcome Test (SNOT-22) scores and Nasal Obstruction Symptom Evaluation (NOSE) scores. Comparisons were made with paired t tests. Results Fifty-three patients met inclusion/exclusion criteria. Sleep outcomes showed a clinically and statistically significant improvement (EpSS before FESS = 14.7 ± 3.1, EpSS after FESS = 9.1 ± 1.1, p < 0.01; PSQI before FESS = 10.9 ± 2.8, PSQI after FESS = 5.3 ± 2.2, p < 0.01). CRS-specific outcomes were improved as well. Nasal obstruction scores did not change significantly. Conclusion FESS improved sleep outcomes for the patients in our study. This was independent of correction of nasal obstruction. Sinus surgery for CRSsNP has a beneficial impact on sleep; this novel information can be used during patient counseling and for justification to third-party payers.

Introduction We report on a case of isolated metastatic breast cancer to the medial rectus muscle. This entity is exceedingly rare. Case A 44-year-old female with a history of breast cancer presented with unilateral maxillary symptoms and was treated for sinusitis. Over time, she developed ocular pain, diplopia, blurred vision and eventually complete adduction deficit. Results T1-weighted magnetic resonance imaging revealed a medial rectus lesion. Biopsy via transnasal transorbital endoscopic approach revealed metastatic mammary carcinoma. Discussion Metastatic disease to the orbit should be considered in the differential diagnosis of refractory maxillary sinus pain in patients with a known underlying malignancy.

Recalcitrant chronic rhinosinusitis without polyposis (CRSsP) is a challenging condition to manage as traditional medical therapies and surgery fail to provide satisfactory clinical improvements. Colloidal silver (CS), a widely used naturopathic agent, has recently shown anti-biofilm properties both in vitro and within a rhinosinusitis animal model. To date, no trials involving humans have been published in world literature. The purpose of this study was to assess the efficacy of CS as a topical nasal spray in patients with refractory CRSsP. A prospective cohort study was conducted using a convenience sample of 20 randomized patients with crossover methodology, comparing nasal sprays with CS versus saline. Patients sprayed twice daily for six weeks with the first intervention and then switched to the second for the next six weeks, with measurements made at baseline and each time point. Primary outcomes were changes in SNOT-22 and Lund-Kennedy (LK) endoscopic scores. All analysis was non-parametric and was conducted using STATA 14. Twenty-two patients were enrolled in the study with 20 completing the entire protocol. Mean 6-week change in SNOT-22 scores were −2.8 and 1.0 for saline and CS, respectively (p = 0.373). Similarly, mean 6-week change in LK scores were −1.4 and −1.1 for saline and CS, respectively (p = 0.794). Significant period effects were observed with the SNOT-22 score between the randomized groups. No participants experienced negative health effects directly attributable to the administration of intranasal CS. Commercially available CS nasal spray did not demonstrate any meaningful subjective or objective improvements in patients with recalcitrant CRSsP. NCT02403479 . Registered on March 1, 2015.

During the 2017 IFOS ENT World Congress, an international expert panel was asked to clarify the role of ENT in the diagnosis process of the obstructive sleep apnea syndrome (OSA) in adults around the world. OSA is a major public health issue throughout the world. OSA is a highly prevalent disease with heavy clinical, social and economical outcomes. This high prevalence raises serious difficulties of diagnosis accessibility if only somnologists are able to confirm OSA diagnosis. First of all, the panellists reviewed the impact of OSA. Secondly, they defined the ENT role stressing ENT legitimacy, professional expertise and academic and institutional tasks. They also defined when somnologists were necessary. For the international panel, the ENT is a major player in the OSA diagnosis process.

This study seeks to determine the objective and subjective success rates of anterior palatoplasty and its variants for the treatment of obstructive sleep apnoea (OSA). A systematic review with two independent searches of Medline, PubMed, Cochrane Library and Evidence Based Medicine Reviews was performed to identify publications relevant to OSA and anterior palatoplasty. All relevant studies published before 30 June 2015 were included. Six studies were included in the systematic review. The numbers of patients in each paper ranged from 13 to 77 (total = 240), and mean age ranged from 21 to 51 years. Substantial and consistent improvement in polysomnography (PSG) outcomes were observed in patients after the anterior palatoplasty, with or without multilevel surgery. The results showed that the anterior palatoplasty technique provides significantly improvement in the post-operative Apnoea-Hypopnea Index. The mean pre-operative AHI (in the 6 papers) improved from 16.3 to 7.1, the snore visual analogue scale improved from 7.5 to 3.1 and the Epworth score reduced from 11.3 to 7.3 post-operatively. The overall pro-rated pooled success rate for all the patients was 72.5%, with a mean follow-up of 17.3 months. Anterior palatoplasty is an effective option in the management of patients with mild to moderate OSA.La palatoplastica anteriore nel trattamento delle apnee ostruttive del sonno: una revisione sistematica.Obiettivo di questo studio è determinare il tasso di successo, oggettivo e soggettivo, della palatoplastica anteriore e delle sue varianti nel trattamento delle apnee ostruttive del sonno. È stata quindi effettuata una revisione sistematica attraverso due ricerche indipendenti utilizzando Medline, PubMed, Cochrane Library and Evidence Based Medicine Reviews al fine di identificare le pubblicazioni di rilievo in merito alle apnee ostruttive del sonno e alla palatoplastica anteriore. Sono stati considerati tutti gli studi importanti pubblicati prima del 30 giugno 2015. Sono stati inclusi sei studi nella revisione sistematica. Il numero di pazienti in ciascun lavoro variava da 13 a 77 (per un totale di 240 pazienti), e l’età media variava da 21 a 51 anni. Dopo la palatoplastica, con o senza “chirurgia multilivello”, è stato osservato un netto e consistente miglioramento dei parametri della polisonnografia. I risultati hanno mostrato che con la palatoplastica anteriore si ottiente un sgnificativo miglioramento dell’Indice di Apnea/Ipopnea (AHI) postoperatorio. Il valore medio (dei 6 lavori) di AHI preoperatorio è migliorato da 16,3 a 7,2 e la scala visuo-analogica del russamento da 7,5 a 3,1, la scala di Epworth, infine, si è ridotta da 11,3 a 7,3. Il tasso di successo globale per tutti i pazienti è risultato pari a 72,5%, considerando un tempo di follow-up medio di 17,3 mesi. In conclusione, la palatoplastica anteriore è un’opzione efficace nella gestione dei pazienti con apnee ostruttive del sonno, di grado lieve e moderato.

Background Office-based rhinologic procedures have become popularized in recent years with the advent of several minimally invasive techniques. There is a paucity of literature, however, that supports more robust in-clinic procedures, e.g., true endoscopic sinus surgery (ESS). There is a high volume of this work being done at our center, and the objective of this article was to review the safety and tolerability of in-clinic surgeries. Methods A retrospective chart review was conducted. All the adult patients who underwent in-clinic sinonasal procedures and surgery with a minimum of 3 months of follow-up were included. Information regarding intra- and postoperative complications and revision procedures were recorded. For the ESS procedures, the indication, sinuses operated on, and type of revision were also collected. Results A total of 315 patients met the inclusion criteria. There were 166 turbinoplasties, 118 ESS, 35 septoplasties, 34 rhinoplasties, and 4 septorhinoplasties performed. For the ESS procedures, 74 (62.7%) were bilateral, and experience was had operating in all paranasal sinuses. All ESS work involved opening diseased ostia and was more than just polypectomies. The mean follow-up for the ESS cases was 13.4 months (range, 12-65 months). Complication rates and tolerability measures were comparable with those of other reported in-office sinonasal procedures performed with the patient under local anesthetic. Conclusion Office-based rhinologic surgery was safe and well tolerated by the patients. The need for revision ESS in our series was low when considering the extent of surgery that was performed. An in-clinic procedure may avoid a general anesthetic in the operating room for appropriately selected patients.

Background Hypertrophy of the lingual tonsil tissue in the adult patient is thought to contribute to the pathophysiology of obstructive sleep apnea. The underlying etiology of lingual tonsil hypertrophy (LTH) in the adult patient is unclear and likely multifactorial. Previous studies have suggested that the lingual tonsils may undergo compensatory hyperplasia post-tonsillectomy in children, although it is unknown if this occurs or persists into adulthood. The purpose of this study was to determine what factors are associated with LTH in a population of Canadian adults. Methods Adult patients presenting for consultation to an academic Rhinology/General Otolaryngology practice were eligible for enrollment. Demographic data including age, body mass index (BMI), Reflux Symptom Index (RSI), history of allergy, and history of tonsillectomy was collected via questionnaire. Endoscopic photographs of the base of tongue and larynx were captured. These were graded for LTH and Reflux Finding Scale (RFS) by blinded examiners. Statistical analysis was performed by comparing the mean LTH value to the variables of interest using two-tailed T-test. P 7 or RSI >13 was considered positive for laryngopharyngeal reflux. There was no difference in LTH based on RSI positivity (p = 0.44). RFS positivity correlated with increased lingual tonsil tissue (p 30 was associated with increased lingual tonsil hypertrophy (p

The accepted definition of silent sinus syndrome (SSS) excludes posttraumatic cases. To challenge current exclusion criteria of antecedent facial trauma, we have identified all published cases of posttraumatic SSS in English literature, including a new representative case from our institution.MEDLINE, EMBASE, and Scopus databases.All case reports and case series published in English literature from 1964 through August 2016 were sequentially identified. Authors of cases with missing information were contacted for completion.Thirteen documented cases of posttraumatic SSS were identified through the literature review. An additional case from our institution was presented, bringing the total reported case count to 14. Time from initial trauma to presentation ranged from 2 months to 32 years, with a median duration of 6 months. Endoscopic sinus surgery (ESS) with either concurrent or staged orbital floor implant repair was used to treat posttraumatic SSS in 64% of reported cases. Three patients had ESS alone, with one case showing postoperative improvement in enophthalmos.Recent emergence of case reports of SSS postorbital and facial trauma challenge the current exclusion criteria of precedent facial trauma. Posttraumatic SSS is rare, but the availability of cross-sectional imaging pre- and postdevelopment of SSS makes a strong case for a causal relationship. Laryngoscope, 127:1520-1524, 2017.

The use of computer simulation to develop a high-fidelity model has been proposed as a novel and cost-effective alternative to help guide therapeutic intervention in sleep apnea surgery. We describe a computer model based on patient-specific anatomy of obstructive sleep apnea (OSA) subjects wherein the percentage and sites of upper airway collapse are compared to findings on drug-induced sleep endoscopy (DISE).Basic science computer model generation.Three-dimensional finite element techniques were undertaken for model development in a pilot study of four OSA patients. Magnetic resonance imaging was used to capture patient anatomy and software employed to outline critical anatomical structures. A finite-element mesh was applied to the volume enclosed by each structure. Linear and hyperelastic soft-tissue properties for various subsites (tonsils, uvula, soft palate, and tongue base) were derived using an inverse finite-element technique from surgical specimens. Each model underwent computer simulation to determine the degree of displacement on various structures within the upper airway, and these findings were compared to DISE exams performed on the four study patients.Computer simulation predictions for percentage of airway collapse and site of maximal collapse show agreement with observed results seen on endoscopic visualization.Modeling the upper airway in OSA patients is feasible and holds promise in aiding patient-specific surgical treatment.NA. Laryngoscope, 128:277-282, 2018.

Objective/Hypothesis Evidence is lacking to guide whether patients with obstructive sleep apnea (OSA) require mandatory postoperative monitoring when undergoing multilevel sleep surgery. The purpose of this study was to examine the respiratory complication rate following OSA surgery and identify which patients benefit from monitoring after surgery. Study Design A prospective study was conducted. Methods Fifty patients (age 45.4 ± 12.4; male 39, female 11), with sleep study-proven OSA (apnoea/hypopnoea index [AHI] 24.3 ± 22.2) underwent multilevel sleep surgery. All patients had the St. Joseph's OSA risk score calculated preoperatively and then again within the postanesthesia care unit (PACU). The patients were then stratified into two categories: safe for same-day discharge and requiring admission for overnight O2 saturation monitoring. Groups were compared across age, sex, AHI, body mass index, mean O2 saturation, minimum O2 saturation, length of time in PACU, narcotic use, smoking, surgery type, and other comorbidities. The St. Joseph's OSA Risk Tool was applied. Results Seventy-eight percent of patients met criteria for same-day discharge, and 22% required admission. For the discharged patients, we had a 0.0% readmission or complication rate for OSA-specific reasons. For the admitted patients, we had no OSA-specific complications while admitted to hospital. No variables consistently predicted complications or need for admission. Conclusions The incidence of respiratory events requiring intervention following multilevel sleep surgery is very low. Most patients with OSA undergoing surgery can be safely discharged home without any subsequent respiratory complications. In addition, those patients admitted for monitoring after surgery do not benefit from their admission. Level of Evidence: 2b. Laryngoscope, 125:498–502, 2015

Background Routine histopathological assessment is standard practice for nasal polyp specimens obtained during endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS). Retrospective studies suggest that routine histopathology of nasal polyps shows few unexpected diagnoses that alter patient management. Our objective was to study the use of routine pathological analysis, and its cost to the healthcare system, in a prospective manner. Methods A multicenter prospective assessment was performed from data collected between 2007 and 2013. Only cases of patients undergoing ESS for bilateral CRS were included. We excluded unilateral disease cases, and cases in which diagnoses other than polyps were suspected either preoperatively or intraoperatively. We then compared the preoperative diagnosis with the final histopathology and identified the rate of unexpected pathologies. A cost analysis was performed. Results Only 4 of 866 pathological specimens were identified as having a clinically significant unexpected diagnosis. All unexpected pathologies in this series were benign. These 4 cases account for 0.46% of all specimens reviewed. This translates to a number needed to screen of 217 cases of bilateral CRS to discover 1 unexpected pathology. The associated cost for making an unexpected diagnosis was $19,192.73. Conclusion Routine histopathology of nasal polyps in ESS for bilateral CRS with polyps yields few unexpected and management-altering diagnoses. It carries a significant cost to the healthcare system. In cases of bilateral CRS with no other concerning clinical features, clinicians should exercise judgment in submitting polyp specimens for pathology rather than routinely sending polyps for histopathologic analysis.

Background Patient-centered care is recognized as being fundamental to successful medical practice. The effectiveness of patient-centered care has classically been measured by posttreatment outcomes, such as patient compliance and psychosocial responses. Systematic assessment of patient concerns prior to treatment has been limited, to date. Endoscopic sinus surgery (ESS) is an elective procedure for chronic rhinosinusitis that carries a clear, defined set of risks. The objective of this prospective observational study was to determine the concerns of patients undergoing ESS for chronic rhinosinusitis. Methods A total of 180 patients undergoing ESS for chronic rhinosinusitis with or without polyposis were recruited at 2 Canadian tertiary care centers. They completed a validated survey assessing their concerns regarding the risks and outcomes of surgery. Data was analyzed using descriptive statistics and analysis of variance. Results Patients had a low degree of concern prior to undergoing surgery (overall score 2.8/9), though individual variability existed. Subjects felt the greatest level of concern regarding potential need for revision surgery as well as the wait time for surgery. Patients were least concerned about psychological factors (mean = 1.8/9). No differences with respect to age or gender were identified. Mean scores for cerebrospinal fluid leak and orbital injury were 3 and 3.2, respectively. Conclusion Patients’ level of concern prior to undergoing elective surgery is generally low. Patients’ areas of greatest concern may not align with those perceived by the physician. This study provides insight into patient concerns prior to undergoing elective sinus surgery and emphasizes the importance of the patient-centered approach to care.

Objectives: The nose and paranasal sinuses contribute to speech resonance and changes to these structures may alter speech nasality. This change may influence one’s vocational and social functioning and quality of life. Our investigation explored objective and subjective changes in nasality following nasal surgery in a prospective and longitudinal fashion. Methods: Recordings of sustained vowel and sentence stimuli and voice-related quality of life measurements were obtained preoperatively and at 2, 4, 8, and 24 weeks postoperatively from individuals undergoing nasal and/or sinus surgery. Objective measures of fundamental frequency, jitter, shimmer, and harmonic to noise ratio (HNR) were determined. Pre- and postoperative speech samples were assessed by 15 naïve listeners. Results: In all, 15 subjects completed the study. Neither speakers nor listeners perceived a subjective change in nasality following surgery. No statistically significant change in microacoustic measures were identified. Although nasal sentences did not reveal differences for 3 microacoustic measures, a difference in HNR was identified. Conclusions: Patients undergoing nasal surgery did not exhibit subjective changes in resonance postoperatively. Aside from a difference in HNR for the nasal sentence, objective microacoustics remained unchanged. These results demonstrate the stability of oranasal resonance despite nasal surgery and provide valuable data for patient informed decision-making.

Objectives/hypothesis To determine patient recall of specific risks associated with medication prescription and whether or not handouts are an effective tool to augment the informed consent process. Study design Double-blinded, randomized, controlled trial. Methods Informed consent for prednisone prescriptions was studied by comparing the effect of a verbal discussion (describing 10 specific adverse drug reactions) in conjunction with a handout going over same, to a verbal discussion alone. Blinded assessments occurred by telephone interview 2 to 4 weeks following the intervention. Outcomes assessed were the number of risks of prednisone that patients could list and the number of risks they recalled having discussed with their physician. Other demographic details were also collected. Results Twenty-five participants were randomly allocated to each group. Without prompting, the median number of risks spontaneously recalled by the handout group was not significantly different than the control group, and both groups had very low recall (two vs. one, P = .24). When provided a list of potential side effects, it was observed that the handout group recalled a higher median number of risks having been discussed with their physician compared to patients in the control group (eight vs. five, P = .003). The groups' demographics were otherwise identical. Conclusions Patients in general did not remember discussing adverse prednisone risks with their physician even a short time after the discussion took place. Although the patient handout resulted in improved recall of risks following the prescription of prednisone, its importance in the informed medication consent process remains an open question. Level of evidence 1b.

Hospitals routinely admit most patients with obstructive sleep apnea (OSA) who undergo surgery for OSA to a high intensity care unit for overnight monitoring after surgery. This practice, mostly based on historical evidence, is designed to monitor respiratory outcomes after surgery in the event of adverse events taking place. However, this also creates inconvenience for patients, is very expensive to the health care system, and uses significant hospital resources. The goal of this systematic review of the literature was to assess what the current evidence is to support this practice and to begin to answer the question of which patients are benefitting from this approach.

Objectives/Hypothesis To assess the efficacy of a novel high-fidelity epistaxis simulator in teaching epistaxis management to junior otolaryngology head and neck surgery residents. Study Design Prospective cohort study. Methods A novel high-fidelity epistaxis task trainer was developed using a cadaver head, intravenous tubing, and a food coloring-filled saline bag to emulate blood. Learners were instructed on two techniques of nasal packing (formal nasal pack and nasal tampon) for the management of epistaxis using the task trainer. Learners were videotaped attempting to pack the nose of the task trainer pre- and postintervention (verbal instruction, and practice time with task trainer). Five board-certified otolaryngologists (blinded to pre- and postintervention status) evaluated the packing technique using standardized subjective outcome measures. Results There were 13 junior otolaryngology residents enrolled in the study. This cohort showed a statistically significant increase in global rating scores (P < 0.05) in all items measured for both packing methods. Conclusion This novel cadaveric epistaxis simulator has been successful in teaching and the practical application of various skills in epistaxis management. This task trainer appears to confer an educational benefit in technical skills acquisition in novice learners. Further studies are needed to determine long-term skill retention. Simulation is a promising educational adjunct that effectively enhances epistaxis management skills acquisition while maximizing patient safety. Level of Evidence NA. Laryngoscope, 2015

Objectives Postoperative debridement is a controversial subject in the rhinology literature. The objective of this randomized controlled trial was to determine the effect of regular debridement versus no debridement on disease-specific outcomes and patient inconvenience. Methods Patients with chronic rhinosinusitis with polyposis who were to undergo basic sinus surgery (antrostomy, ethmoidectomy, and polypectomy) were randomized to either debridement (at postoperative weeks 2 and 4) or no debridement, and their outcomes were assessed at 4 weeks and at 6 months with the Lund-Kennedy Endoscopic Score (LKES), the Sino-Nasal Outcome Test-21 (SNOT-21), a visual analog scale for postoperative pain, and a novel scoring system for postoperative inconvenience (Post-Operative Inconvenience Scale; POIS). All patients were instructed to use high-volume saline rinses twice daily. Results At 4 weeks after operation, there was no difference between the groups in regard to LKESs (control group, 2.1 of 20; debridement group, 2.4 of 20; p = 0.59) or SNOT scores (control group, 9.1; debridement group, 8.3; p = 0.47). The visual analog scale pain scores showed significance (control group, 19 mm; debridement group, 38 mm; p = 0.019), as did the POIS scores (control group, 18.3; debridement group, 6.1; p = 0.002). At 6 months after surgery, again no difference was seen between the groups on either LKESs or SNOT scores. Conclusions In our patient population, debridement after surgery did not affect disease-specific outcomes.

Background Intranasal medication delivery for allergic rhinitis (AR) is considered a mainstay of therapy but is hampered by poor compliance. Among reasons given are unpleasant sensations associated with spray penetration into the pharynx. Our objective was to study a novel method of particle delivery to the nose that would abrogate these issues. Methods This was a double-blind, randomized study. Subjects who met study criteria underwent intranasal particle delivery using a novel device (Trivair Nasal Deposition System; Trimel Pharmaceuticals, Toronto, Canada) that delivered anhydrous lactose particles into the nose via a transoral air puff (thus elevating soft palate and blocking the nasopharynx). Subjects had nostrils randomized into 4 groups (particle sizes 5 μm and 50 μm × doses 12.5 mg and 25 mg). Particle deposition was assessed at 1 minute, 10 minutes, and 30 minutes on the inferior turbinate, middle turbinate, and nasopharynx, respectively, using high-definition endoscopic photography. Each image was compared using an expert blinded 2-person panel for percentage particles remaining. Nonparametric data was assessed using the Wilcoxon signed-rank test via Strata software. Results Twelve nostrils in total met study criteria. The results showed no difference in effectiveness of nasal particle retention between the groups based on particle size or dose. No particles entered the nasopharynx or oropharynx. Conclusion This study provides proof-of-principle data that the Trivair Nasal Deposition System is effective at retaining medication in the nose without pharyngeal penetration. Larger studies on this device are warranted.

Objectives To critically review the current literature regarding aspirin desensitization treatment for nasal polyposis in patients with Aspirin-Exacerbated Respiratory Disease (AERD). Study Design Systematic review of the literature. Methods All English literature published between January 1995 and February 2013 reporting specifically nasal outcomes following aspirin desensitization in AERD patients were eligible for inclusion. Exclusion criteria were non-investigative, non-human, and ex-vivo studies. Studies were categorized by level of evidence and evaluated for quality using the Downs and Black scale. Results A total of 614 citations were retrieved and eleven studies met the criteria for analysis. Outcome measurements included self-reported symptom scores, amount of corticosteroid use, rate of revision surgery, and quantitative measurements such as rhinomanometry. Overall, most studies reported a significant improvement in symptom scores, decrease in corticosteroid use, and decrease in revision surgery. A few studies showed promising results with quantitative outcomes. However, most studies were of Level 2 evidence with small samples sizes. Rates of adverse events ranged from 12.5% to 23%. Conclusions Unlike traditional treatments for nasal polyposis, aspirin desensitization targets AERD etiology rather than phenotype and can be an effective therapeutic option. While the current literature shows encouraging results, additional studies are needed to better define clinical benefits.

Background The problem of postoperative management after frontal sinus surgery remains a challenge. The bilateral opening created in the Draf III procedure does not fit any currently available stent, and patients find rinsing the frontal sinus difficult, which thus decreases compliance. The objective of this study was to demonstrate the successful use of a novel frontal sinus catheter fashioned from a biliary T tube by addressing these issues in patients with complicated sinus disease. Methods This was a review of 30 patients who underwent a Draf III procedure between January and October 2014, and who had a T-tube stent inserted at the end of the procedure. Patient charts were analyzed for complications such as bleeding, infection, and restenosis as well as indications of ease of rinsing ability after surgery. Results From the chart data, there was only one intraoperative bleed and only one postoperative bleed that required packing. Four patients had infections that required antibiotics after surgery. At the time of data collection, only one patient had signs of restenosis as judged by the operating surgeon. Patients reported an ease of rinsing ability with the T-tube stent. Conclusions The novel biliary T-tube stent use presented in this article is a promising future direction for postoperative care after extended frontal sinus surgery.

To evaluate the success rates of combined Expansion Sphincter Pharyngoplasty and the Anterior Palatoplasty in the treatment of OSA. A two center prospective series of 73 patients with OSA. All patients were >18 years old, retro-palatal obstruction, concentric velo-pharyngeal collapse, BMI

Chronic rhinosinusitis (CRS) in aspirin-exacerbated respiratory disease (AERD) represents a recalcitrant form of sinonasal inflammation for which a multidisciplinary consensus on patient management has not been reached. Several medical interventions have been investigated, but a formal comprehensive evaluation of the evidence has never been performed. The purpose of this article is to provide an evidence-based approach for the multidisciplinary management of CRS in AERD.A systematic review of the literature was performed and the guidelines for development of an evidence-based review with recommendations were followed. Study inclusion criteria included: adult population18 years old; CRS based on published diagnostic criteria, and a presumptive diagnosis of AERD. We focused on reporting higher-quality studies (level 2 or higher) when available, but reported lower-quality studies if the topic contained insufficient evidence. Treatment recommendations were based on American Academy of Otolaryngology (AAO) guidelines, with defined grades of evidence and evaluation of research quality and risk/benefits associated with each treatment.This review identified and evaluated the literature on 3 treatment strategies for CRS in AERD: dietary salicylate avoidance, leukotriene modification, and desensitization with daily aspirin therapy.Based on the available evidence, dietary salicylate avoidance and leukotriene-modifying drugs are options following appropriate treatment with nasal corticosteroids and saline irrigation. Desensitization with daily aspirin therapy is recommended following revision endoscopic sinus surgery (ESS).

Background:In otolaryngology, surgical emergencies can occur at any time. An annual surgical training camp (or ‘boot camp’) offers junior residents from across North America the opportunity to learn and practice these skills in a safe environment. The goals of this study were to describe the set-up and execution of a simulation-based otolaryngology boot camp and to determine participants' confidence in performing routine and emergency on-call procedures in stressful situations before and after the boot camp.Methods:There were three main components of the boot camp: task trainers, simulations and an interactive panel discussion. Surveys were given to participants before and after the boot camp, and their confidence in performing the different tasks was assessed via multiple t-tests.Results:Participants comprised 22 residents from 12 different universities; 10 of these completed both boot camp surveys. Of the nine tasks, the residents reported a significant improvement in confidence levels for six, including surgical airway and orbital haematoma management.Conclusion:An otolaryngology boot camp gives residents the chance to learn and practice emergency skills before encountering the emergencies in everyday practice. Their confidence in multiple skillsets was significantly improved after the boot camp. Given the shift towards competency-based learning in medical training, this study has implications for all surgical and procedural specialties.

Objectives/Hypothesis: The objective of this study was to evaluate the long-term effectiveness of palatal implants as the treatment of primary snoring. Study Design: Prospective longitudinal cohort study. Methods: This study compared snoring outcomes before and after soft palate implantation for patients diagnosed with primary snoring (no sleep apnea). Snoring severity was obtained by the subjects' sleep partners on a 10-point Likert scale. A paired Student t test compared the mean scale values preoperatively at week 52 and at the current 4-year follow-up. Body mass index for each patient was also compared to evaluate for any significant confounders. Results: Data were obtained from 23 patients out of 26 who were followed for the full study term. The follow-up time was on average 4 years following palatal implantation. A statistically (P < .016) and clinically significant improvement in the snoring scale was noted when comparing snoring severity between the preoperative and 4-year period and between the 52-week and 4-year scores. Although statistically significant improvement was found between the preoperative period and 52 weeks, there was a clinical deterioration in snoring scale scores between 52 weeks and 4 years. The mean (standard deviation) preoperative score was 9.5 (0.5), mean week-52 score was 5.0 (1.6), and mean 4-year score was 7.0 (1.8). Body mass index did not change through the observation interval. Conclusions: Soft palate implantation is a possible surgical technique with which to attempt to achieve subjective improvement of primary snoring severity. Subjective improvement, however, deteriorates significantly over time, and is only minimally sustained at 4 years postoperatively. This study provides new information on long-term palatal implant effectiveness.

Objectives: We evaluated the lateral crural J-flap technique in the surgical repair of external nasal valve collapse with standardized and validated outcome measurements. Methods: Prospective data were gathered on consecutive cases, performed by a single surgeon between 2007 and 2010, of adult patients who underwent a lateral crural approach to repair of external nasal valve collapse. Data were collected on diagnosis, surgical outcomes, and complications. Outcome measures included the Nasal Obstructive Symptom Evaluation and the Rhinoplasty Outcome Evaluation. Results: Fifteen patients were included in the study. Their follow-ups ranged from 9 to 13 months. All patients had statistically significant improvements in Nasal Obstructive Symptom Evaluation scores. There was no significant change in perceived nasal appearance after surgery as measured by the Rhinoplasty Outcome Evaluation. There were no surgical complications. Conclusions: The lateral crural J-flap approach to repair of external nasal valve collapse is a technically straightforward and relatively safe procedure. The efficacy is excellent at the 1-year follow-up examination.

Evidence is lacking to guide the postoperative management of Samter's triad patients with chronic rhinosinusitis with polyposis (CRSwP) undergoing endoscopic sinus surgery (ESS). The purpose of this study was to compare three different standardized medication regimens prescribed to these patients after ESS.Three-arm, randomized, double-blinded, controlled trial.Patients with Samter's triad undergoing ESS were postoperatively randomized into three medication regimens, those being saline irrigation alone (control group A), saline irrigation plus separate budesonide nasal spray (group B), and saline irrigation mixed with budesonide nasal spray (group C). Outcome measures were Sino-Nasal Outcome Test scores, Lund-Mackay computed tomography scores, and Lund-Kennedy endoscopic scores taken at preoperative baseline, and then at 6 months and 1 year postoperatively. Side effect profiles were also measured (adrenocorticotropic hormone blood level ranges and intraocular pressure at the same interval points). Analysis of variance and χ(2) analyses were conducted using a Bonferroni correction method and routine descriptive statistics. Inter- and intragroup comparisons were made.Sixty subjects were recruited. All groups were equivalent at baseline in all outcomes. All intragroup analyses showed statistically and clinically significant improvement in disease status as compared to baseline (P.0167), with a sustained but lessened improvement at 1 year. However, no statistically or clinically significant differences were observed between groups at any time point (P.05). There was no treatment effect noted.In this study, nasal steroids did not confer any additional benefit over saline alone as post-ESS care for the Samter's triad CRSwP patient population.

Objectives: Chronic rhinosinusitis with nasal polyposis is often refractory to medical and surgical management, especially in patients with asthma and aspirin intolerance. We used a contemporary database to investigate recurrence and revision surgery rates following endoscopic sinus surgery. Methods: We performed a cohort study using a survival analysis technique. Records were reviewed of 549 patients with nasal polyposis who underwent endoscopic sinus surgery over a 10-year period. The main outcome measure was disease-free and surgery-free survival following endoscopic sinus surgery, investigated with Kaplan-Meier analyses. Results: Patients with Samter's triad were significantly more likely to have a recurrence and undergo a second surgery following recurrence (risk-odds ratio, 2.7; 95% confidence interval, 1.5 to 3.2; p < 0.01) than were patients without asthma or with only asthma from the triad. The presence of initial frontal sinus disease also increased the likelihood of revision surgery (risk-odds ratio, 1.6; 95% confidence interval, 1.2 to 1.8; p < 0.05). Conclusions: This is the first study to use survival analysis to document revision surgery rates following endoscopic sinus surgery. Revision surgery occurs at a high rate, especially in patients with asthma, Samter's triad, or frontal sinus disease. Patients should routinely be informed during clinical consultations about the likelihood of recurrence. Early intervention for frontal sinus disease may be considered.

Objectives:To describe the tumor characteristics and visual function in conservatively managed patients with non-functioning pituitary macroadenoma (NFMA) that contacted/compressed the visual pathway.Design:Retrospective case-series.Setting:Tertiary-care academic institution.Participants:Six patients with diagnosis of NFMA.Main Outcome:Visual function and radiological characteristics of the optic apparatus and pituitary tumor.Results:All patients had radiological evidence of optic apparatus compression but only one had visual field defect at the initial presentation. While two of the six patients developed visual field changes during follow-up (41±34.8 months), the patient with visual field defect at the time of diagnosis improved to normal vision.Conclusions:Select NFMAs that contact the optic apparatus, without visual dysfunction, may be managed with close ophthalmological and radiographic monitoring, depending on tumor and imaging characteristics. This may be of particular relevance in patients considered to have a high peri-operative risk, such as advanced age or significant co-morbidities.

To assess the utility of image-guided transnasal endoscopic surgery for a variety of orbital diseases requiring decompression of at least one orbital wall.A descriptive case series of consecutive orbital procedures requiring decompression of at least one wall. All procedures were performed using a transnasal endoscopic approach and an intraoperative image-guided LandmarX system for anatomical guidance.A 3-year review yielded 17 cases, including 6 cases with compressive mucoceles, 4 neoplasms, 4 patients with proptosis secondary to Graves' Ophthalmopathy, 1 case of an intraorbital abscess, 1 fungal mycetoma, and 1 hemangioma. These cases all had improved postoperative clinical status without any serious complications. The LandmarX system was a valuable intraoperative tool in all 17 cases.The endoscopic transnasal approach to orbital decompression surgery allows for good visualization and is minimally invasive. Using this approach in conjunction with the LandmarX image-guided system allows for improved anatomical localization and provided good results in all cases.

Objectives/Hypothesis: To critically review current literature comparing microscopic versus endoscopic surgery in the treatment of pituitary adenomas. Study Design: Systematic review of the literature. Methods: All English language literature published between January 1989 and June 2009 on PubMed were eligible for inclusion. Inclusion criteria were: direct comparison between microscopic and fully endoscopic approaches and surgery performed with the intent to treat a pituitary adenoma. Endoscopic-assisted comparisons and studies comparing outcomes with previous literature were excluded. Technical notes, case reports, letters, and comments were also excluded. Included studies were categorized according to level of evidence and evaluated for quality using a modified Downs and Black scale. Data was extracted and compared between studies. Results: Of the 3,586 studies retrieved from the search strategy, 11 studies met the inclusion and exclusion criteria. Various outcomes measures were used including: operating time, extent of tumor resection, postoperative normalization of hormone levels, incidence of complications, length of hospital stay, and patient pain and discomfort. The endoscopic approach decreased operating time, lumbar drains, immediate postoperative diabetes insipidus, some rhinologic complications, length of hospital stay, and patient pain and discomfort. Other outcome measures were comparable between the two approaches. Conclusions: The literature comparing endoscopic and microscopic pituitary surgery favors the endoscopic approach for pituitary surgery. Major outcome measures (extent of tumor resection, changes in hormone levels) do not differ between the two approaches. Complications, time in the operating room and hospital, and patient discomfort are significantly less with the endoscopic approach. Laryngoscope, 2010

Objectives/Hypothesis: To determine if an association exists between sleep apnea, daytime somnolence, and chronic idiopathic dizziness. Study Design: Case-control study of new patients presenting to a tertiary neuro-otologic practice. A total of 46 subjects with idiopathic dizziness (ID), 20 positive controls with dizziness (benign paroxysmal positional vertigo [BPV]), and 69 negative controls with hearing loss (HL) but no dizziness were enrolled. Methods: Participants who were patients diagnosed with the above conditions and who met all other inclusion criteria completed a sleep questionnaire and had a complete physical exam and investigations to establish or exclude a neuro-otologic diagnosis. They were subsequently evaluated for risk of symptomatic sleep disturbance based on the Epworth Sleepiness Scale (ESS), the Berlin Questionnaire, and the Multivariable Apnea Risk Index (MAP). Statistical analysis was carried out using SPSS (SPSS Inc., Chicago, IL). Results: There was no significant demographic difference among the groups in terms of age, sex, body mass index, neck size, alcohol consumption, or smoking. Using a cutoff of both 10 and 12 on the ESS, the ID were more likely to have significant daytime somnolence than the HL group, with a likelihood ratio (LR) of 7.8 for the ESS 12 score (P = .021) and 7.1 for the ESS 10 score (P = .029). Using the MAP score, a statistically significant difference between the ID group and both the BPV group (LR 3.99, P = .046) and the HL group (LR 5.46, P = .019) was found. Conclusions: This study suggests that a previously undescribed link between idiopathic dizziness, daytime somnolence, and sleep apnea might exist. Prospective investigation is warranted to determine whether treatment of any sleep issues resolves symptoms of idiopathic dizziness.

Objectives/Hypothesis: Recent guidelines from the American Society of Anesthesiologists recommended postoperative monitoring for most patients undergoing surgery for obstructive sleep apnea (OSA). These guidelines, however, are largely based on retrospective literature and expert opinion. The appropriate level of postoperative monitoring remains controversial. Our objective was to prospectively document the early postoperative course of patients undergoing OSA surgery. Study Design: Prospective cohort study. Methods: One hundred twenty-one patients (age 43.9 ± 13.5 years, 79.8% male) with sleep-study proven OSA (apnea-hypopnea index 31.9 ± 22.7) who were undergoing surgery for OSA at our tertiary care center were recruited from 2007 to 2009. Outcome measures were: 1) incidence of respiratory complications requiring nursing intervention, 2) level of postoperative blood oxygen saturation divided into three groups: mean oxygen saturation in recovery room (SpO2recovery), mean oxygen saturation in step-up unit (SpO2step-up), and lowest oxygen saturation over the 24 hour period (SpO2minimum). These results were then compared to the benchmark literature. Results: The overall incidence of nursing intervention in response to a respiratory complication (3.4%) was significantly less than expected (P < .002). Mean SpO2recovery was 92.9 ± 3.2%, SpO2step-up was 95.9 ± 1.6%, and SpO2minimum was 92.8 ± 3.1%. No variables were identified as being predictive of any of the outcome measures. Conclusions: The incidence of respiratory events requiring intervention in the early postoperative course of OSA patients was low (3.4%). Routine postoperative inpatient monitoring may not be required in many cases. Laryngoscope, 2010

The primary objective of this descriptive and correlational study was to determine the level of pain and discomfort perceived by children undergoing nasendoscopy for investigation of voice and resonance disorders. The secondary objective was to explore whether gender, age, previous experience of painful or distressing medical procedures, and previous experience of nasendoscopy influenced the perception of pain during nasendoscopy. Twenty-three children self-reported the degree of pain perceived during nasendoscopy using the Wong-Baker Faces Pain Rating Scale. Parents also used this scale to rate their child's perceived pain. Otolaryngologists and speech pathologists rated the intensity and frequency of observed pain-related behaviors using the Child-Adult Medical Procedure Interaction Scale-Revised and the Procedure Behavior Checklist. Children perceived the procedure, on average, to be moderately painful, as did their parents. Only two children reported perceiving no pain during the procedure. The most frequently observed pain-related behaviors were muscle tension (86.96%), physical resistance (69.57%), requiring physical restraint (60.87%), crying (43.48%), and expressions of verbal pain (39.13%). No significant correlations were found between self-reported pain or observed pain and the variables of age, gender, previous experience of nasendoscopy, and previous experience of painful or distressing medical procedures, although children aged 4-7 years reported significantly more pain than children aged 8-18 years. Most children perceive nasendoscopy to be painful to some degree. This perceived pain occurred in conjunction with several observable pain-related behaviors that have the potential to interfere with the success of the procedure.

Objectives: To determine whether computer-assisted learning (CAL) is an effective tool for the instruction of technical skills. Study Design: Prospective blinded randomized-control trial conducted on a cohort of 47 first-year medical students. Methods: Students were instructed on two techniques of nasal packing (formal nasal pack and nasal tampon) for the management of epistaxis, using either a standard text-based article or a novel computer-based learning module. Students were evaluated on proper nasal packing technique using standardized subjective and objective outcome measures by three board-certified otolaryngologists. Blind assessments took place prior to and following instruction, using the assigned learning modality. Results: There were 47 participants enrolled in the study. Both groups demonstrated improvement in performance of both packing procedures following training. A significant post-training difference favoring CAL learners over text-based learners was observed, using the global assessment of skill for both packing techniques (P < .001). Additionally, a significant post-training difference favoring CAL learners over text-based learners was observed for all checklist items for the tampon pack and five of eight items on the formal pack checklist. The vast majority of students (94.6%) indicated that if given the choice, they would prefer to learn using CAL rather than by using text-based learning materials. Conclusions: CAL learners demonstrated significantly greater improvement across both subjective and objective outcome measures when compared to the text-based group. Additionally, students favored learning via the CAL modality, which further suggests that CAL is a valuable means of imparting procedural knowledge to novice medical trainees. Laryngoscope, 119:466–472, 2009

To assess perioperative quality-of-life (QOL) changes in a facial plastic surgery patient population and to ascertain factors determinative of QOL changes. A notable paucity of objective scientific measurements of QOL exists within the facial plastic surgery literature.A 3-year prospective cohort study. The patient population, which comprised a consecutive series of patients 16 years or older, undergoing cosmetic nasal or facial surgery, was obtained from the senior author's (P.A.A.) private surgical practice. All patients presenting for surgery were offered participation. The main outcome measure was the 59-item Derriford Appearance Scale (DAS59), a valid and reliable instrument assessing psychological distress associated with self-consciousness of facial appearance. Three patient score subgroupings were established: group 1, the DAS59 scores for all patients; group 2, the DAS59 score according to sex; and group 3, the DAS59 score according to the main surgical procedure. Surveys were administered to eligible patients at the final preoperative clinic visit and at 3 months after surgery. Data from the case-control groups were analyzed by a blinded statistician with appropriate t tests.A total of 93 patients were enrolled with a 100% response rate (82 females [88%] and 11 males [12%]). The most common procedures were rhinoplasty (49%) and surgery for the aging face (51%). Marked differences in perioperative QOL were noted across all DAS59 domains for group 1 and for all females in group 2. Male patients in group 2 analysis experienced QOL improvement only from DAS59 domain 2 (General Self-consciousness of Facial Appearance). Rhinoplasty and surgery for the aging face improved patients' QOL but differed with respect to which DAS59 domains were affected.Quality of life was enhanced by facial plastic surgery in this patient population. Male and female patients seem to have different needs to be met from facial cosmetic surgery and correspondingly different areas of improvement in QOL. Rhinoplasty and surgery for the aging face act on different domains of QOL.

OBJECT The relationship between headaches, pituitary adenomas, and surgical treatment of pituitary adenomas remains unclear. The authors assessed the severity and predictors of self-reported headaches in patients referred for surgery of pituitary adenomas and evaluated the impact of endoscopic transsphenoidal surgery on headache severity and quality of life (QOL). METHODS In this prospective study, 79 patients with pituitary adenomas underwent endoscopic transsphenoidal resection and completed the Headache Impact Test (HIT-6) and the 36-Item Short Form Health Survey (SF-36) QOL questionnaire preoperatively and at 6 weeks and 6 months postoperatively. RESULTS Preoperatively, 49.4% of patients had mild headache severity, 13.9% had moderate severity, 13.9% had substantial severity, and 22.8% had intense severity. Younger age and hormone-producing tumors predisposed greater headache severity, while tumor volume, suprasellar extension, chiasmal compression, and cavernous sinus invasion of the pituitary tumors did not. Preoperative headache severity was found to be significantly associated with reduced scores across all SF-36 QOL dimensions and most significantly associated with mental health. By 6 months postoperatively, headache severity was reduced in a significant proportion of patients. Of the 40 patients with headaches causing an impact on daily living (moderate, substantial, or intense headache), 70% had improvement of at least 1 category on HIT-6 by 6 months postoperatively, while headache worsened in 7.6% of patients. The best predictors of headache response to surgery included younger age, poor preoperative SF-36 mental health score, and hormone-producing microadenoma. CONCLUSIONS The results of this study confirm that surgery can significantly improve headaches in patients with pituitary adenomas by 6 months postoperatively, particularly in younger patients whose preoperative QOL is impacted. A larger multicenter study is underway to evaluate the long-term effect of surgery on headaches in this patient group.

To determine patient recall of specific risks associated with endoscopic sinus surgery and whether an adjunct multimedia education module is an effective patient tool in enhancing the standard informed consent process.Prospective, randomized, controlled trial.Fifty consecutive adult patients scheduled for endoscopic sinus surgery at a rhinology clinic of a tertiary care hospital were recruited for this study. Informed consent was studied by comparing the number of risks recalled when patients had a verbal discussion in conjunction with a 6-minute interactive module or the verbal discussion alone. Early recall was measured immediately following the informed consent process, and delayed recall was measured 3 to 4 weeks after patient preference details were also collected.Early risk recall in the multimedia group was significantly higher than the control group (P = .0036); however, there was no difference between the groups in delayed risk recall. Seventy-six percent of participants expressed interest in viewing the multimedia module if available online between the preoperative and procedural day. Sixty-eight percent of patients preferred having the multimedia module as an adjunct to the informed consent process as opposed to the multimedia consent process alone.There is an early improvement in overall risk recall in patients who complete an interactive multimedia module, with a clear patient preference for this method. Here we emphasize the well-known challenges of patient education and demonstrate the effectiveness of integrating technology into clinical practice in order to enhance the informed consent process.1b Laryngoscope, 126:1273-1278, 2016.

Traumatic optic neuropathy (TON) represents a rare but devastating complication of closed head injuries. No accepted guidelines are available for medical and surgical management algorithms. A systematic review of the literature was performed to determine the optimal timing and candidacy for endoscopic surgical intervention.A systematic review of multiple databases was performed including Medline-Ovid, EMBASE, and PubMed. Data was extracted and patients stratified based on surgical delay from trauma (≤3 days,3 days, ≤7 days, or7 days) as well as preoperative and postoperative vision testing (no light perception [NLP]; light perception [LP]; hand motion [HM]; or finger counting [FC] or better).The literature review identified 24 studies meeting inclusion criteria. In the group of patients receiving surgery ≤3 days after the antecedent event, 57% (105/183) had visual improvement, whereas in the7-days group 51% (145/283) of patients improved. In those with NLP preoperatively, 41% (172/411) saw improvement, whereas those with LP (89%), HM (93%), or FC (85%) fared better.The literature suggests that surgical intervention for TON is indicated despite delayed presentation, and is a better choice than no intervention at all. Patients with complete blindness on presentation (NLP) tend to have a poorer surgical outcome.

Background Controversy regarding the usefulness of routine histopathological examination of bilateral nasal polyps removed during endoscopic sinus surgery to identify occult diagnoses still exists. There is a paucity of high-level evidence in the literature. Methods A systematic review and meta-analysis was conducted. Two independent reviewers were used. Pooled proportions and numbers needed to screen were calculated. A cost per life year model was generated based on varying survival benefits and compared to other Canadian screening programs to provide financial context. Results Six studies (n = 3772 patients) were included. Of the 3772 patients, 3751 had a pre-operative clinical and post-operative pathological diagnosis of inflammatory nasal polyps. Agreement proportion was 99.44 %. There were 18 unexpected benign and three unexpected malignant diagnoses identified. This translated to a proportion of 0.48 and 0.08 % respectively. Number needed to screen was 210 and 1258 respectively. Pooled proportion for expected findings using a random effect model was 0.99 (95 % CI = 0.99–1). Pooled proportion for unexpected benign findings using a random effect model was 0.00522 (95 % CI = 0.00133–0.01). Pooled proportion for unexpected malignant findings using a random effect model was 0.00107 (95 % CI = 0.000147–0.00283). The cost to pick up one unexpected benign diagnosis was $14557.2. The cost to pick up 1 unexpected malignant diagnosis was $87204.56. Cost per quality life year calculated ranged from 3211.83 to $64677.58 based on varying assumptions on the survival benefits of identifying an unexpected malignancy. Conclusions Routine pathological examination in screening for neoplasia may be low yield, however, no compelling evidence was found to cease such practice. Surgeons should exercise individual judgment in requesting routine examination. Electronic supplementary material The online version of this article (doi:10.1186/s40463-015-0100-8) contains supplementary material, which is available to authorized users.

Aspirin-exacerbated respiratory disease (AERD) is a clinical triad consisting of aspirin/acetylsalicylic acid (ASA) sensitivity, bronchial asthma, and nasal polyposis. Although respiratory reactions following ingestion of ASA and other nonsteroidal anti-inflammatory drugs (NSAIDs) are considered a hallmark of the condition, respiratory inflammation persists despite patients' avoidance of NSAIDs. Treatment of this condition remains challenging and includes both medical and surgical options.A prospective crossover single-blind multicenter study involving 4 tertiary rhinology care centers (n = 30) was conducted in which patients were randomized to start with either 6 weeks of a regular diet or 6 weeks of a low-salicylate diet and then crossed-over for a total study duration of 12 weeks. Patients were evaluated at baseline, 6 weeks (at crossover) and 12 weeks using subjective measures (22-item Sino-Nasal Outcome Test-22 [SNOT-22], Nasal Sinus Symptom Scale [NSSS], and 7-item Asthma Control Questionnaire [ACQ-7]) and objective outcome instruments (Perioperative Sinus Evaluation [POSE] and Lund-Kennedy Endoscopic Score [LKES]).Data was analyzed for 30 patients. Wilcoxon rank sum tests determined that patients had improvement in their median difference in scores, which were all statistically significant, when they followed the low-salicylate diet compared to their regular diet: SNOT-22: 15 (95% confidence interval [CI], 10 to 23.25), p0.001; NSSS: 3 (95% CI, 1.75 to 4), p0.001; ACQ-7: 4.5 (95% CI, 1.5 to 8.5), p0.001; POSE 6 (95% CI, 2.5 to 10), p0.001; and LKES: 2.5 (95% CI, 1.5 to 4), p0.001).The low-salicylate diet may offer a novel treatment adjunct to the current management of AERD. Clinically and statistically significant improvements on both subjective and objective outcome measures were noted for the upper and lower respiratory tracts.