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Background: The utility of clinician-applied instruments, particularly the Lund-Mackay score, in the assessment of paranasal sinus computed tomography (CT) in chronic rhinosinusitis (CRS) remains incompletely defined. The purpose of this study was to determine if a new approach to the evaluation of sinus CT could accurately predict the extent of opacification while remaining simple for clinician use., Methods: Twenty-four sinus CT scans were measured for the percent of sinus opacification using three-dimensional (3D) volumetric analyses. The same scans were also evaluated using the Lund-Mackay score to measure opacification and the Assessment of Pneumatization of the Paranasal Sinuses (APPS) score to measure total sinus volume (TSV). Correlation analysis was performed for the Lund-Mackay to APPS score ratio as a predictor of percent opacification. Validation analysis was also performed to determine the optimal orientation for Lund-Mackay scoring, which has not previously been described., Results: The Lund-Mackay to APPS score ratio was very strongly correlated with the percentage of sinus opacification measured by 3D volumetric analysis (r = 0.862, r 2 = 0.743, p < 0.001). Lund-Mackay scoring was not statistically different between axial-only, coronal-only, or triplanar groups for interrater (p = 0.379) and intrarater reliability (p = 0.312)., Conclusion: The Lund-Mackay score is validated for rater reliability in multiple orientations. Using the APPS score as a measure of TSV, the Lund-Mackay-to-APPS ratio very strongly correlates with the percentage of sinus opacification by 3D volumetric analysis. Further study will be required to determine if this ratio is predictive of symptom severity., (© 2016 ARS-AAOA, LLC.)

Background: The Assessment of Pneumatization of the Paranasal Sinuses (APPS) score is a novel and validated instrument for comprehensively evaluating the pneumatization pattern of the sinuses. Previous studies on the relationship between sinus pneumatization and clinical parameters have been hindered by cumbersome volume analysis. The purpose of this study was to determine whether the APPS score correlates with total sinus volume., Methods: Semiautomated 3-dimensional (3D) volume analysis of 20 consecutive sinus computed tomography (CT) scans was performed. Total paranasal sinus volume (TSV) for each scan was then calculated. Relative total paranasal sinus volume (RTSV) was calculated by dividing TSV by the volume of the right globe. An independent reviewer then scored each CT scan using the APPS instrument. The elapsed time to perform 3D analysis and APPS scoring was recorded for each CT scan., Results: The APPS score was strongly correlated with TSV by Pearson's correlation coefficient (r = 0.893). The coefficient of determination (r 2 ) was 0.797. The APPS score was also strongly correlated with RTSV (r = 0.851, r 2 = 0.724). The mean elapsed time of 3D volume analysis for each CT scan was significantly greater than for APPS scoring (1187 vs. 37 seconds, p < 0.001)., Conclusion: The APPS score correlates strongly with both TSV and RTSV. Evaluation of paranasal sinus pneumatization by APPS score is also significantly faster than a semiautomated method for 3D volumes. The APPS instrument can be used to study large populations for relationships between clinical parameters and sinus volume., (© 2016 ARS-AAOA, LLC.)

Background: Cerebrospinal fluid (CSF) rhinorrhea, when left untreated, can lead to meningitis and other serious complications. Treatment traditionally has entailed an open craniotomy, although the paradigm has now evolved to encompass endoscopic procedures. Trauma, both accidental and iatrogenic, causes the majority of leaks, and trauma involving skull base and facial fractures is most likely to cause CSF rhinorrhea. Diagnosis is aided by biochemical assay and imaging studies., Methods: We reviewed the literature and summarized current practice regarding the diagnosis and management of CSF rhinorrhea., Results: Management of CSF leaks is dictated by the nature of the fistula, its location, and flow volume. Control of elevated intracranial pressure may require medical therapy or shunt procedures. Surgical reconstruction utilizes a graduated approach involving vascularized, nonvascularized, and adjunctive techniques to achieve closure of the CSF leak. Endoscopic techniques have an important role in select cases., Conclusion: An active surgical approach to closing CSF leaks may provide better long-term outcomes in some patients compared to more conservative management.

Objective: Chronic inflammation has been described as a precursor to the development of malignancy in several disease states. However, the relationship of sinonasal tract inflammation to nasopharyngeal carcinoma (NPC) remains poorly defined., Data Sources: Systematic review of primary studies identified through PubMed, EMBASE, MEDLINE, and Cochrane., Methods Review: Systematic review and meta-analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. MEDLINE, EMBASE, and Cochrane databases were queried for English-language studies published between 1980 and 2015. Studies were excluded that did not provide quantitative data on sinonasal tract inflammation such as chronic rhinosinusitis (CRS), allergic rhinitis (AR), or human papillomavirus (HPV) status and NPC. An itemized assessment of the risk of bias was conducted for each included study., Results: Of the 325 studies identified during systematic review, 5 met the criteria for analysis. The level of evidence of those studies was generally low. There was an increased risk of NPC in patients with a previous diagnosis of CRS or AR. Meta-analysis demonstrated an odds ratio (95% confidence interval [CI]) of 2.35 (2.00-2.76) for all studies. Subgroup analysis of patients with sinonasal inflammation had an odds ratio of 2.39 (95% CI, 2.20-2.60). Patients with AR had an odds ratio of 2.29 (95% CI, 2.06-2.54), while those with CRS had an odds ratio of 2.70 (95% CI, 1.98-3.70)., Conclusions: This systematic review and meta-analysis suggests an association between previous sinonasal inflammatory disease and subsequent NPC. Prospective studies are needed to further examine this relationship., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.)

Background: The purpose of this study was to develop and validate a radiographic metric for characterizing the degree of paranasal sinus pneumatization. A validated metric for the extent of sinus pneumatization that comprehensively includes the maxillary, ethmoid, frontal, and sphenoid cavities is not currently available., Methods: A validation study was performed in which 5 independent reviewers evaluated 49 sinus computed tomography (CT) scans in coronal, sagittal, and axial orientations. Reviewers evaluated each scan, bilaterally, for 18 proposed dichotomous items as part of the Assessment of Pneumatization of the Paranasal Sinuses (APPS) metric. Evaluation of APPS items was independent of sinus opacification, which was simultaneously evaluated using the standard and validated Lund-Mackay scoring system. Interrater and intrarater reliability was assessed for each proposed APPS parameter and Lund-Mackay item using Fleiss kappa statistic., Results: Nine parameters were included in the final APPS metric due to substantial interrater reliability (κ(mean) = 0.61, κ(range) = 0.41-0.81) and intrarater consistency (κ(mean) = 0.64, κ(range) = 0.53-0.77), variable radiographic presence, and unique contribution to the characterization of sinus pneumatization. Kappa values were also calculated for Lund-Mackay interrater reliability (κ(mean) = 0.58, κ(range) = 0.45-0.66) and intrarater consistency (κ(mean) = 0.71, κ(range) = 0.65-0.75). The final APPS metric has comparable interrater and intrarater reliability to Lund-Mackay scoring. APPS scores were normally distributed within the study group by Anderson-Darling normality test (p < 0.005)., Conclusion: The APPS score is the first comprehensive and validated metric for quantifying the degree of paranasal sinus pneumatization and anatomic variation. This has important potential utility in standardizing evaluation of sinus CT and researching the relationship of sinus pneumatization with clinical parameters., (© 2015 ARS-AAOA, LLC.)

Objective: Paranasal sinus balloon catheter dilation (BCD) represents a commonly used tool in the management of chronic rhinosinusitis (CRS) for which the indications, utilization, and outcomes have not been well established. A systematic review and meta-analysis were undertaken to evaluate change in quality of life and sinus opacification following paranasal sinus BCD in the treatment of CRS., Data Sources: MEDLINE and EMBASE databases., Review Methods: Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were utilized to identify English-language studies reporting patient outcomes following BCD for CRS. Primary outcomes included the impact of BCD on validated measures of quality of life and sinonasal opacification., Results: Systematic review identified 17 studies for qualitative analysis. Studies generally included cases with limited disease based on radiographic opacification. Five studies contained extractable data for change in 20-Item Sinonasal Outcome Test (SNOT-20) 1 year following BCD, with significant improvement in self-reported quality of life (P = .04). Five studies reported a significant change in paranasal sinus opacification following BCD (P < .001). Two studies directly compared change in SNOT-20 between BCD and endoscopic sinus surgery, without demonstration of significant difference in outcome (P = .07). Subgroup analysis found that change in SNOT-20 score was greater after BCD in the operating room than in the office (P = .004)., Conclusion: Current evidence supporting the role of BCD in CRS remains incomplete. Long-term within-group improvements in quality-of-life and sinus opacification scores are demonstrated among a restricted adult population with CRS. Additional study is needed to further evaluate the role for BCD in specific settings and patient subgroups., (© American Academy of Otolaryngology-Head and Neck Surgery Foundation 2015.)

Background: Endoscopic transsphenoidal surgical approaches to the skull base may produce alteration of intranasal architecture. Acoustic rhinometry (AR) can provide quantitative data on the nasal airway, which has not been previously applied to skull base surgery. We sought to employ AR to quantify the changes in nasal patency following endoscopic transsphenoidal surgery and identify the relationship between these changes and septal deviation, nasoseptal flap harvest, and sinonasal quality of life (QOL)., Methods: Consecutive patients undergoing endoscopic transsphenoidal resection of a sellar or suprasellar tumor were prospectively enrolled. All subjects were adults who completed AR and the 22-item Sino-Nasal Outcome Test (SNOT-22) preoperatively and postoperatively. Cross-sectional area (CSA) was recorded at the internal nasal valve (CSA1), middle turbinate head (CSA2), and middle turbinate body (CSA3). Normative data were also collected from a larger cohort., Results: Forty patients met study criteria. Significant increases occurred postoperatively in mean CSA2 (1.08 cm(2)) and CSA3 (2.47 cm(2)) (p < 0.001), whereas CSA1 remained unchanged. Nasoseptal flap harvest and correction of septal deviation did not significantly alter mean postoperative AR values. Mean SNOT-22 scores were comparable despite septal pathology, whereas strong correlation was not found with change in AR values. Preoperative and postoperative QOL scores were not significantly affected by the presence of nasal septal deviation., Conclusion: The endoscopic transsphenoidal approach to the skull base can result in increased intranasal area without a detrimental effect on sinonasal QOL. These effects are independent of nasoseptal flap harvest and correction of nasal septal deviation., (© 2015 ARS-AAOA, LLC.)

Object: Pituitary adenomas are well suited to resection by a minimal-access endoscopic technique. Validation of this approach requires prospective outcome studies to determine the impact on quality of life (QOL). This study aims to assess the effect of endoscopic pituitary adenoma resection on site-specific and sinonasal-related QOL before and after endoscopic surgery using validated instruments., Methods: Consecutive adult patients undergoing endoscopic endonasal resection of pituitary adenoma were prospectively enrolled from a single tertiary care center. All patients completed the Anterior Skull Base Questionnaire (ASBQ) and the 22-Item Sino-Nasal Outcome Test (SNOT-22) preoperatively and then at regular intervals after surgery to assess their perceived QOL with regard to hormonal, surgical, and anatomical factors., Results: Eighty-one of 114 patients were eligible for study; median follow-up was 16 months. This cohort included 24 (29.6%) nonsecreting macroadenomas and 57 (70.4%) hypersecreting tumors. There was significant improvement in the mean ASBQ score at 12 weeks, 6 months, and 1 year after surgery (p < 0.05), while postoperative SNOT-22 scores, at the same time points, showed no significant difference from preoperative scores. Both ASBQ and SNOT-22 scores showed transient worsening at 3 weeks postoperatively. Subtotal resection correlated with worse QOL, both overall and among patients with hypersecreting tumors (p < 0.05). Extrasellar tumor extension, intraoperative CSF leakage, and a reconstruction technique during surgery did not impact postoperative QOL. Visual disturbances did not significantly alter QOL. There were no postoperative CSF leaks in this series., Conclusions: Endoscopic resection of pituitary adenoma is associated with long-term improvements in site-specific QOL and stability in sinonasal QOL when assessed pre- and postoperatively with validated instruments. Subtotal resection was the only factor that negatively impacted postoperative QOL. Therefore, gross-total resection should be attempted for all patients to optimize QOL after surgery.

Object: Craniopharyngiomas are benign parasellar tumors for which surgical removal, although potentially curative, often leads to morbidity with resulting decreases in quality of life (QOL). The endonasal endoscopic approach is a minimal-access technique for removing these tumors and may reduce postoperative morbidity. The QOL following this method for resection of craniopharyngiomas has not been documented., Methods: The authors reviewed a database of consecutive endonasal endoscopic surgeries done at Weill Cornell Medical College. Adult patients with histologically proven craniopharyngiomas were included who had completed either only postoperative (> 9 months) or both pre- and postoperative QOL forms, the Anterior Skull Base Quality of Life (ASBQ) questionnaire, and the 22-Item Sinonasal Outcome Test (SNOT-22). Rates of gross-total resection (GTR), complications, and visual and endocrine function were collected. Retrospective independence (Wen score) was also assigned. A contemporaneous group of patients undergoing endonasal endoscopic pituitary macroadenoma resection was used as a control., Results: This study included 33 procedures performed in 31 patients. The average postoperative ASBQ score was 3.35 and the SNOT-22 score was 19.6. Better QOL was associated with GTR and postoperative radiation. Worse QOL was associated with persistent visual defects, hypopituitarism, tumor recurrence, increase in body mass index, and worsening Wen score. In a subset of 10 patients, both pre- and postoperative (> 9 months) QOL scores were obtained. Both ASBQ and SNOT-22 scores showed stability and a trend toward improvement, from 2.93 ± 0.51 to 2.96 ± 0.47 (ASBQ) and 23.7 ± 10.8 to 18.4 ± 11.6 (SNOT-22). Compared with 62 patients undergoing endoscopic pituitary macroadenoma resection, patients with craniopharyngiomas had worse postoperative QOL on the ASBQ (3.35 vs 3.80; p = 0.023) and SNOT-22 (19.6 vs 13.4; p = 0.12)., Conclusions: This report of validated site-specific QOL following endoscopic surgery for craniopharyngiomas shows an overall maintenance of postoperative compared with preoperative QOL. Better QOL could be seen in patients with GTR and radiation therapy, and worse QOL was found in patients with visual or endocrine deficits. Nevertheless, patients with craniopharyngiomas still had worse QOL than those undergoing similar surgery for pituitary macroadenomas, confirming the worse prognosis of craniopharyngiomas even when removed via a minimally invasive approach. These measures should serve as benchmarks for comparison with open transcranial approaches to similar tumors.

Object: This study details the extent of resection and complications associated with endonasal endoscopic surgery for pituitary tumors invading the cavernous sinus (CS) using a moderately aggressive approach to maximize extent of resection through the medial CS wall while minimizing the risk of cranial neuropathy and blood loss. Tumor in the medial CS was aggressively pursued while tumor in the lateral CS was debulked in preparation for radiosurgery., Methods: A prospective surgical database of consecutive endonasal pituitary surgeries with verified CS invasion on intraoperative visual inspection was reviewed. The extent of resection as a whole and within the CS was assessed by an independent neuroradiologist using pre- and postoperative Knosp-Steiner (KS) categorization and volumetrics of the respective MR images. The extent of resection and clinical outcomes were compared for medial (KS 1-2) and lateral (KS 3-4) lesions., Results: Thirty-six consecutive patients with pituitary adenomas involving the CS who had surgery via an endonasal endoscopic approach were identified. The extent of resection was 84.6% for KS 1-2 and 66.6% for KS 3-4 (p = 0.04). The rate of gross-total resection was 53.8% for KS 1-2 and 8.7% for KS 3-4 (p = 0.0006). Six patients (16.7%) had preoperative cranial neuropathies, and all 6 had subjective improvement after surgery. Surgical complications included 2 transient postoperative cranial neuropathies (5.6%), 1 postoperative CSF leak (2.8%), 1 reoperation for mucocele (2.8%), and 1 infection (2.8%)., Conclusions: The endoscopic endonasal "medial-to-lateral" approach permits safe debulking of tumors in the medial and lateral CS. Although rates of gross-total resection are moderate, particularly in the lateral CS, the risk of permanent cranial neuropathy is extremely low and there is a high chance of improvement of preexisting deficits. This approach can also facilitate targeting for postoperative radiosurgery.

Objective: To describe the effect on postoperative cerebrospinal fluid (CSF) leak after anterior skull base (ASB) surgery and complications associated with the addition of the vascularized nasoseptal flap (NSF) to an existing reconstruction protocol., Methods: A prospective database of all patients undergoing endoscopic ASB approaches was reviewed. Patients were divided into three groups based on the date the use of the NSF was adopted. Group A included patients with high-volume CSF leak closed using the NSF in addition to a multilayer closure. Group B included patients operated on during the same time period with no high-volume leak and no NSF. Group C included patients operated on before the adoption of the NSF with all types of CSF leak. Rates of intraoperative and postoperative CSF leak were analyzed for statistical significance., Results: Of 415 consecutive patients undergoing endoscopic ASB surgery, there were 96 in group A, 114 in group B, and 205 in group C. CSF leak rates in group A (3.1%) and group B (2.6%) were significantly lower than in group C (5.9%; P < 0.05). Lumbar drains and the gasket seal closure were performed more frequently in group A (75% and 32%) compared with group B (21% and 12%) and group C (28% and 11%). NSF carried a 2% risk of postoperative mucocele., Conclusions: The addition of NSF to an algorithm for multilayer closure can decrease the rate of postoperative CSF leak., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Endoscopic skull-base surgery (ESBS) is a minimal access approach to cranial base pathology; however, it significantly disrupts the intranasal mucosa and intranasal structures, the long-term effects of which are still being studied. We prospectively assessed postoperative changes in sinonasal QOL symptoms following ESBS., Methods: Eighty-five patients were prospectively assessed with the Anterior Skull Base Questionnaire (ASBQ), a validated QOL instrument, preoperatively and up to 1 year postoperatively at each subsequent office visit. A subset of these data was analyzed to assess the effect of endoscopic pituitary surgery on postoperative taste, smell, appetite, nasal secretions, and vision., Results: ESBS patients were divided into 2 cohorts: those undergoing pituitary adenoma surgery and those undergoing ESBS for all other pathologies. Preoperative smell (3.11 vs 3.76, p = 0.03) and taste (3.04 vs 3.69, p = 0.03) were significantly lower in the nonpituitary group. Within the pituitary group both taste (3.69 vs 2.95, p = 0.03) and smell (3.76 vs 2.61, p ≤ 0.001) were significantly decreased by 6 weeks postoperatively. However, by 12 months both taste and smell scores returned to baseline. Vision scores improved by 3 weeks postoperatively with durable results at 1 year (2.80 vs 3.33, p = 0.04 vs 3.59, p = 0.03, respectively). Within the nonpituitary group, smell was decreased at 3 weeks, but was not significantly changed at any other time points., Conclusion: Our study indicates a dissociation between the nasal and visual QOL after ESBS. While nasal QOL transiently decreases, visual QOL progressively improves. These data should not be lumped together for the purposes of statistical analysis., (© 2013 ARS-AAOA, LLC.)

Background: Nasal endoscopy is an important part of the clinical evaluation of patients with chronic rhinosinusitis. However, the objectivity and interrater agreement of the procedure related findings have not been well studied, especially in patients who have previously had sinus surgery., Methods: Patients with a history of endoscopic sinus surgery for chronic rhinosinusitis were prospectively enrolled from a tertiary rhinology practice. Fourteen endoscopic nasal examinations were recorded using digital video capture software. Each patient also underwent computed tomography (CT) and completed the Sinonasal Outcome Test (SNOT-22). Blinded review of inflammatory and anatomic findings for each video was independently performed by 5 academic rhinologists at separate institutions. Comparisons were performed using the unweighted Fleiss' kappa statistic (K(f) ) and the prevalence- and bias-adjusted kappa (PABAK)., Results: There were no significant correlations between age, Lund-Mackay score, or SNOT-22 score. Interrater agreement was variable across the characteristics studied. Mean PABAK was excellent for the assessment of polyps (K(f) = 0.886); moderate for the assessments of middle turbinate (MT) integrity (K(f) = 0.543), MT position (K(f) = 0.443), maxillary sinus patency (K(f) = 0.593), and ethmoid sinus patency (K(f) = 0.429); fair for discharge (K(f) = 0.314), synechiae (K(f) = 0.257), and middle meatus patency (K(f) = 0.229); and poor for MT mucosal changes (K(f) = 0.148) and uncinate process (K(f) = 0.126)., Conclusion: This study was notable for variability in the interrater agreement among the inflammatory and anatomic attributes that were examined. Further standardization of nasal endoscopy with regard to interpretation may improve the reliability of this procedure in clinical practice., (Copyright © 2012 American Rhinologic Society-American Academy of Otolaryngic Allergy, LLC.)

Objectives/hypothesis: Methicillin-resistant Staphylococcus aureus (MRSA) has been isolated from patients with acute rhinosinusitis (ARS) and chronic rhinosinusitis (CRS), although the exact prevalence is unknown. Similarly, the optimal treatment regimen for MRSA sinusitis has not been determined. The aim of this study was to summarize the existing data on prevalence and treatment outcomes for MRSA sinusitis in nonhospitalized patients., Study Design: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines., Methods: MEDLINE, Embase, and Cochrane databases were queried for English-language studies published between 1942 and 2012. Studies were excluded that did not provide quantitative data on the prevalence or treatment of ARS or CRS with MRSA-positive cultures. An itemized assessment of the risk of bias was conducted for each included study., Results: Of 409 studies identified during systematic review, 12 studies met the criteria for analysis. The level of evidence and freedom from bias of these studies were generally low. The prevalence of MRSA among all culture isolates ranged from 0% to 15.9% for ARS and 1.8% to 20.7% for CRS. Six studies reported quantitative treatment outcomes using variable measures, in which resolution of infection ranged from 58.3% to 100%. The treatment regimens were heterogeneous and included single- and multiple-agent therapy with oral, topical, and parental antibiotics., Conclusions: MRSA-positive cultures are found in a small but significant number of cases of ARS and CRS. Treatment of MRSA sinusitis may be effective, although treatment regimens and outcome measures are variable. Prospective studies utilizing standardized parameters are warranted., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

Introduction The endoscopic endonasal approach to the parapharyngeal space (PPS) and jugular foramen is not well defined. We sought to systematically define the important landmarks and limitations of this new surgical technique using an endoscopic transmaxillary transpterygoid corridor. Methods Endoscopic dissection was performed in both sides of two latex-injected cadaver heads. Left-sided dissections were facilitated by the addition of a sublabial maxillary antrostomy. The pterygopalatine fossa, infratemporal fossa, and PPS were sequentially dissected and the endoscopic perspective was examined. Measurements were obtained from the surgical orifices to the upper cervical internal carotid artery (ICA) and internal jugular vein (IJV). Results Successful access to the PPS and jugular foramen was achieved in each dissection. The lateral pterygoid plate, mandibular branch of the trigeminal nerve, middle meningeal artery, levator veli palatini muscle, Eustachian tube, and stylopharyngeal fascia were identified as landmarks for the upper cervical ICA and the IJV. The mean distance from the nasal sill was markedly greater than from an ipsilateral sublabial antrostomy. Conclusion The endoscopic endonasal approach can provide adequate access to the PPS, carotid sheath, and jugular foramen. Multiple landmarks are useful to guide the dissection within these deep spaces and may facilitate the clinical application of this approach.

Object: Endoscopic skull base surgery (ESBS) is a minimal-access technique that provides an alternative to traditional approaches. Patient-reported outcomes are becoming increasingly important in measuring the success of surgical interventions. Endoscopic skull base surgery may lead to improvements in quality of life (QOL) since natural orifices are used to reach the pathology; however, sinonasal QOL may be negatively affected. The purpose of this study was to assess the impact of ESBS on both site-specific QOL, using the Anterior Skull Base Questionnaire (ASBQ), and sinonasal-related QOL, using the Sino-Nasal Outcome Test (SNOT-22)., Methods: Consecutive patients from a tertiary referral center who were undergoing ESBS were prospectively enrolled in this study. All patients completed the ASBQ and SNOT-22 preoperatively as well as at regular intervals after ESBS., Results: Sixty-six patients were included in the study, and 57.6% of them had pituitary adenoma. There was no significant decline or improvement in the ASBQ-measured QOL at 3 and 6 weeks after ESBS, but there were significant improvements at 12 weeks and 6 months postoperatively (p < 0.05). Improvements were noted in all but one ASBQ subdomain at 12 weeks and 6 months postsurgery (p < 0.05). Preoperative QOL was significantly worse in patients who had undergone revision surgery and significantly improved postoperatively in patients who underwent gross-total resection (p < 0.05). Scores on the SNOT-22 worsened at 3 weeks postoperatively and returned to baseline thereafter. The presence of a nasoseptal flap or a graft-donor site did not contribute to a decreased QOL., Conclusions: Endoscopic skull base surgery is associated with an improvement in postoperative site-specific QOL as compared with the preoperative QOL. Short-term improvements are greater if gross-total resection is achieved. Sinonasal QOL transiently declines and then returns to preoperative baseline levels. Endoscopic skull base surgery is a valuable tool in the neurosurgical management of anterior skull base pathology, leading to improvements in site-specific QOL.

Cholesterol granulomas (CGs) are benign, expanding cystic lesions surrounded by a thick fibrous capsule and filled with fluid, formed by the degradation of blood elements. The goal of surgery is to open the granuloma widely, creating a well-drained cavity. The endonasal endoscopic approach for this extradural lesion is a minimal access method for surgical removal or fenestration. The role of balloon dilation in creating a wide fenestration has not been previously described. The authors describe a patient with a recurrent petrous apex CG who underwent an endoscopic, endonasal, transmaxillary transpterygoid approach to the petrous apex. A balloon sinuplasty catheter was used to dilate the surgical fenestration to maintain continued patency. The authors report on their first experience using balloon dilation combined with endoscopic drainage of the petrous apex. The excellent surgical outcome of this minimally invasive technique holds promise for future endonasal approaches to the middle cranial fossa.

Objectives/hypothesis: Eustachian tube dysfunction (ETD) is a common condition that is associated with otologic and rhinologic symptoms. The complete assessment of ETD is limited without a valid symptom score. We developed and conducted initial validation of the seven-item Eustachian Tube Dysfunction Questionnaire (ETDQ-7), a disease-specific instrument to assess symptoms with respect to ETD., Study Design: Validation study., Methods: The ETDQ-7 was developed using standard survey methodology. The ETDQ-7 was completed by a group of 50 consecutive adult patients diagnosed with ETD and 25 non-ETD patients who served as a control group. Tympanometry was used as a criterion standard to distinguish the two groups. A subset of respondents repeated the ETDQ-7 at a time point 4 weeks later., Results: Content validity for the ETDQ-7 was established by focus group and review of the literature. Reliability testing indicated acceptable internal consistency for the entire instrument (Cronbach α = .71). The test-retest reliability indicated good correlation between the two questionnaires completed by the same patient 4 weeks apart (r = 0.78). The ETDQ-7 was able to discriminate between patients with ETD and those without (P < .001), indicating excellent discriminant validity., Conclusions: The ETDQ-7 is a valid and reliable symptom score for use in adult patients with ETD that may facilitate clinical practice by highlighting the impact of ETD. Further testing is needed to determine its usefulness in assessing treatment response., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

Background: Eustachian tube dysfunction (ETD) is a common condition without an effective, accepted treatment. Balloon dilation Eustachian tuboplasty (BDET) has been recently proposed for the management of ETD. Previous studies of Eustachian tube function and treatment have not included a validated assessment of patient symptoms. We report for the first time the outcomes of BDET using a validated disease-specific symptom score, the 7-item Eustachian Tube Dysfunction Questionnaire (ETDQ-7)., Methods: Consecutive patients undergoing BDET were prospectively enrolled from an otolaryngology practice at a tertiary care medical center. Inclusion criteria were adults with a diagnosis of ETD based on symptoms and abnormal tympanogram. Patients with craniofacial abnormalities or active infection were excluded from study. Primary outcome measures included the ETDQ-7 score, tympanometry, and otoscopic appearance. Secondary measures included the 22-item Sinonasal Outcome Test (SNOT-22) score., Results: Twenty-two consecutive patients underwent 35 BDET procedures. Significant postoperative improvement was seen in tympanometry and otoscopic appearance (p < 0.001). ETDQ-7 scores at 3 weeks, 6 weeks, 12 weeks, and 6 months postoperatively were significantly improved over baseline (p < 0.001). ETDQ-7 scores showed fair correlation with SNOT-22 scores (r > 0.65). ETDQ-7 change scores demonstrated good responsiveness and sensitivity to clinical change following BDET., Conclusion: BDET is an effective surgical intervention for the treatment of ETD in adults. Postoperative improvements were observed using objective and subjective measures. The ETDQ-7 is a valid, disease-specific instrument for the assessment of treatment outcomes and may be applied for clinical use in patients with ETD. Further study is necessary to determine long-term effectiveness., (Copyright © 2011 American Rhinologic Society-American Academy of Otolaryngic Allergy, LLC.)

Background: Epidermoid and dermoid cysts are uncommon entities that belong in the differential diagnosis of ventral skull base lesions. The endoscopic endonasal approach is an attractive option for management of these lesions with limited morbidity. The clinical characteristics and management course from our experience is reviewed along with the relevant literature., Methods: A prospective database of endoscopic endonasal skull base cases performed since 2003 at a tertiary referral center was reviewed for cases involving keratinaceous lesions. Data on the pathology, radiology and management of the disease was reviewed. A search of pertinent literature using Medline was performed to complement the discussion., Results: Three cases of intracranial keratinaceous cysts successfully managed with the endoscopic endonasal approach. All cases presented with headache, and 1 case presented with bitemporal hemianopsia. Characteristic appearance on magnetic resonance imaging was seen in each case. All lesions were intradural with variable involvement of the suprasellar, prepontine, and premedullary cisterns. Total resection was achieved in 2 cases and near total resection in 1 case. Postoperative cerebrospinal fluid leak occurred in one case, which was controlled after revision surgery using the "gasket-seal" technique. There were no cranial nerve palsies or vascular events., Conclusion: The endoscopic endonasal approach allows the rhinologic surgeon to access the ventral midline skull base for the successful management of keratinaceous cysts without major complications., (Copyright © 2011 American Rhinologic Society-American Academy of Otolaryngic Allergy, LLC.)

Objectives/hypothesis: The surgical management options for eustachian tube dysfunction have historically been limited. The goal of the current study was to evaluate the technical considerations, learning curve, and potential barriers for balloon dilation of the eustachian tube (BDET) as an alternative treatment modality., Study Design: Prospective preclinical trial of BDET in a cadaver model., Methods: A novel balloon catheter device was used for eustachian tube dilation. Twenty-four BDET procedures were performed by three independent rhinologists with no prior experience with the procedure (eight procedures per surgeon). The duration and number of attempts of the individual steps and overall procedure were recorded. Endoscopic examination of the eustachian tube was performed after each procedure, and the surgeon was asked to rate the subjective difficulty on a five-point scale., Results: Successful completion of the procedure occurred in each case. The overall mean duration of the procedure was 284 seconds, and a mean number of 1.15 attempts were necessary to perform the individual steps. The mean subjective procedure difficulty was noted as somewhat easy. Statistically shorter duration and subjectively easier procedure were noted in the second compared to the first half of the series, indicating a favorable learning curve. Linear fissuring within the eustachian tube lumen without submucosal disruption (nine procedures, 37%) and with submucosal disruption (five procedures, 21%) were noted. The significance of these physical findings is unclear., Conclusions: Preclinical testing of BDET is associated with favorable duration, learning curve, and overall ease of completion. Clinical trials are necessary to evaluate safety and efficacy., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

Background: Endoscopic skull base surgery (ESBS) is considered a minimally-invasive surgical modality with less morbidity and patient discomfort. Quality-of-life (QOL) assessments provide a patient-reported estimate of well-being that may be clinically relevant. Although the sinonasal tract is integral to ESBS, the change in sinonasal-related QOL with ESBS has not been well studied. The aim of this study was to prospectively assess QOL before and after ESBS using validated outcome measures., Methods: Consecutive adult patients undergoing ESBS for anterior skull base lesions were prospectively enrolled from a tertiary referral center. Each patient was asked to complete the 22-item Sinonasal Outcome Test (SNOT-22) and the Anterior Skull Base Questionnaire (ASBQ) preoperatively, and again at 3 weeks, 6 weeks, 12 weeks, 6 months, and 1 year postoperatively., Results: Eighty-five patients were included for study, 44.7% of whom underwent ESBS for nonpituitary pathology. Mean SNOT-22 scores transiently worsened in the early postoperative period, and significantly improved at 1 year after surgery (p < 0.01). Gross-total tumor resection and use of autologous grafting materials were associated with improved SNOT-22 scores at later time points (p < 0.05). Type of reconstruction, tumor pathology, and functionality did not affect QOL scores. Correlation between SNOT-22 and ASBQ scores was good at all time points (r < -0.50). Cerebrospinal fluid leak and other complications were uncommon., Conclusion: ESBS does not have a detrimental long-term effect and is associated with ultimate improvement in sinonasal-related QOL. Short-term impairments of sinonasal-related QOL are predictable and self-limited. Prospective assessment using sinonasal-related and site-specific QOL instruments provide complementary information about ESBS outcomes., (Copyright © 2012 American Rhinologic Society-American Academy of Otolaryngic Allergy, LLC.)

Background: Surgical access to the cavernous sinus (CS) has proven a challenge for the skull base surgeon. Traditional approaches include the transcranial route, which broaches the lateral wall of the CS and has a high risk of cranial nerve weakness. A medial approach is more logical but the microscopic transsphenoidal approach has a restricted view. The endoscopic endonasal approach provides an alternative medial approach with improved visualization to that provided with the microscope. We describe our results using this approach for resection of CS tumors., Methods: A retrospective chart review was performed of all patients treated surgically at a tertiary care referral center between January 2004 and February 2011 with a purely endoscopic endonasal approach to the CS., Results: Out of 400 total endoscopic skull base cases, 41 (10.3%) involved the cavernous sinus. The most common approach was the transsphenoidal transsellar approach (31 patients, 75.6%). Other approaches included the tran-sethmoidal transsphenoidal parasellar (4 patients, 9.8%) and transmaxillary transpterygoidal (6 patients, 14.6%). The most common pathology was pituitary macroadenoma (24 patients, 58.5%). Gross total resection was achieved in 18 patients (43.9%). Cerebrospinal fluid (CSF) leak was not encountered in any patient postoperatively. Complications included 1 case of new postoperative VIth nerve palsy, 1 case of intraoperative hemorrhage, 2 cases of persistent diabetes insipidus, and 2 cases of sinusitis., Conclusion: The endoscopic endonasal approach is a safe and effective option for tumor resection in the CS using a medial to lateral route for selected cases. Morbidity is low and a variety of reconstructive options are available., (Copyright © 2011 American Rhinologic Society-American Academy of Otolaryngic Allergy, LLC.)

We conducted a retrospective study to compare the clinical characteristics of external auditory canal cholesteatoma (EACC) with those of a similar entity, keratosis obturans (KO). We also sought to identify those aspects of each disease that may lead to complications. We identified 6 patients in each group. Imaging studies were reviewed for evidence of bony erosion and the proximity of disease to vital structures. All 6 patients in the EACC group had their diagnosis confirmed by computed tomography (CT), which demonstrated widening of the bony external auditory canal; 4 of these patients had critical erosion of bone adjacent to the facial nerve. Of the 6 patients with KO, only 2 had undergone CT, and neither exhibited any significant bony erosion or expansion; 1 of them developed osteomyelitis of the temporal bone and adjacent temporomandibular joint. Another patient manifested KO as part of a dermatophytid reaction. The essential component of treatment in all cases of EACC was microscopic debridement of the ear canal. We conclude that EACC may produce significant erosion of bone with exposure of vital structures, including the facial nerve. Because of the clinical similarity of EACC to KO, misdiagnosis is possible. Temporal bone imaging should be obtained prior to attempts at debridement of suspected EACC. Increased awareness of these uncommon conditions is warranted to prompt appropriate investigation and prevent iatrogenic complications such as facial nerve injury.

Eustachian tube dysfunction (ETD) is a common condition that lacks a widely accepted treatment. Attempts to address ETD surgically have spanned several centuries and have often fallen short of success. It is probable that occult anatomic position, unclear function, and misunderstood physiology have contributed to the delayed development of effective interventions for ETD. This article traces the evolution of therapeutic interventions of the Eustachian tube through the present day. Reasons for success and failure are highlighted, with implications for the future of Eustachian tube surgery., (Copyright © 2011 The American Laryngological, Rhinological, and Otological Society, Inc., Rhinological, and Otological Society, Inc.)

Objective: To systematically review outcomes of reinnervation techniques for the management of unilateral vocal fold paralysis (UVFP)., Data Sources: Medline and Cochrane databases for English-language studies published between 1966 and 2009 on the surgical management of UVFP., Review Methods: Studies were excluded if they reported on bilateral vocal fold paralysis, used nonhuman subjects, or did not assess clinical outcomes. Outcomes of interest were visual analysis, acoustic analysis, perceptual analysis, and electromyography., Results: Of 686 initial studies, 14 studies encompassing 329 patients were eligible for analysis. All studies had a case-series design. Of reported patients, 60.2 percent were men, with mean age of 51 years (range, 12-79 years). The most common reinnervation technique was ansa cervicalis-to-recurrent laryngeal nerve (RLN), which was most commonly performed after thyroidectomy (43.5%). Other techniques with reportable outcomes included primary RLN anastomosis, ansa-to-RLN combined with cricothyroid muscle-nerve-muscle pedicle, ansa-to-thyroarytenoid neural implantation, ansa-to-thyroarytenoid neuromuscular pedicle, and hypoglossal-to-RLN. Median postsurgical follow-up was 12 months, and mean time to first signs of reinnervation was 4.5 months (SD 2.9 months). Visual analysis of glottic gap showed the greatest mean improvement with ansa-to-RLN, from 2.25 (SD 0.886) to 0.75 (SD 0.886) mm (P < 0.01). Acoustic analysis showed greatest improvement with neural implantation, with a change in mean phonation time from seven (SD 1.22) to 16 (SD 5.52) seconds (P < 0.01). Perceptual analysis and electromyography demonstrated improvement in all studies., Conclusion: Reinnervation is effective in the management of UVFP, although the specific method may be dictated by anatomical limitations. Prospective studies utilizing uniform and consistent outcome parameters are necessary., (Copyright © 2010 American Academy of Otolaryngology-Head and Neck Surgery Foundation. Published by Mosby, Inc. All rights reserved.)

In response to a unique societal need, a dedicated tonsil hospital was established in New York City in 1921. Its contributions were both medical and moral. The hospital's director, Robert Fowler, impressed by the variability of available surgical techniques, undertook a quest for the "better tonsil operation." His findings, published in an exhaustive text, highlighted several obscure anatomic relationships. Emphasis was on the primacy of anatomic mastery over the allure of new technology, with attention to the path leading from better surgery to better outcomes. Fowler's advocacy of both technical excellence and specialized patient care prefigured similar concerns held by otolaryngologists today., (2010 American Academy of Otolaryngology-Head and Neck Surgery Foundation. Published by Mosby, Inc. All rights reserved.)

Objectives: Although published abstracts have the advantage of being prominent and concise, their quality in the otolaryngology literature has not been studied. We sought to understand the limitations of relying on abstracts as the sole source of information about published research. In addition, we sought to identify specific opportunities for improving the quality of published articles and their associated abstracts., Methods: Studies of original research published in four major otolaryngology journals from January 2008 to June 2008 were included. Each study article and abstract was reviewed separately for 12 domains relating to study design, results, and conclusions. Good inter-rater reliability was established as part of the validation process., Results: Four hundred eighteen articles were identified for study, which included 75 percent clinical research and 25 percent basic science. The most common omissions in the abstract when compared with the complete article were study limitations (91% left out of abstract), geographic location (79%), confidence intervals (75%), dropouts or losses (62%), and harms and adverse events (44%). Conversely, the abstract often included information about research design (99%), sample size (92%), source of the data (81%), and quantitative results (67%). These results did not differ significantly with regard to article type, journal, or level of evidence., Conclusions: Readers of otolaryngology journals may form biased or inappropriate conclusions if they read only the abstract of a study, particularly with regard to study limitations, adverse events, and subject dropouts or losses. These results highlight the perils of using the abstract as a sole source of information., (Copyright 2010 American Academy of Otolaryngology-Head and Neck Surgery Foundation. Published by Mosby, Inc. All rights reserved.)

Acute airway obstruction in the adult can be caused by a rapidly enlarging laryngeal cyst that may present unusually as a midline neck mass. In this case report we present a different surgical technique for the removal of a large combined laryngocele via midline transcervical approach that did not require laryngofissure. This technique allowed simple and fast access, excellent exposure and complete removal of the lesion without resection of thyroid cartilage or associated morbidities.

Thyroglossal duct cyst and lingual thyroid are two common anomalies of thyroid gland development. Each may occur without the thyroid gland in the normal anatomic position, although the association of these three anomalies together is rare. Ectopic thyroid may function abnormally, and this determination can help guide surgical management. Therefore, early evaluation by an endocrinologist is an important part of the therapeutic approach. We report on the presentation and management of a 14-year-old girl with multiple foci of thyroid ectopia, absent orthotopic thyroid gland, and hypothyroidism.

Objectives: To pool and meta-analyze the reported outcomes in patients receiving radiotherapy for T2 glottic carcinoma with impaired vocal cord mobility., Data Sources: A MEDLINE search and manual search were conducted to identify all studies published between January 1, 1950 and September 30, 2007, in English on the treatment of T2 glottic carcinoma. Search terms included laryngeal neoplasm, glottis, and glottic carcinoma., Study Selection: All studies of primary radiotherapy for T2 glottic carcinoma with explicit reporting of outcomes with regard to the presence or absence of vocal cord immobility were included in the meta-analysis. Studies with data reported elsewhere were excluded., Data Extraction: A meta-analysis using a fixed-effects model was conducted for outcome measures of local disease control, ultimate survival after salvage surgery, absolute survival, and disease-specific survival. Odds ratios (ORs), 95% confidence intervals (CIs), and tests for heterogeneity were reported., Data Synthesis: Thirty-five studies were identified, of which 21 met criteria for meta-analysis. All studies were retrospective. Comparison of 5-year local control of disease for lesions with impaired vocal cord mobility (T2b) vs those with normal vocal cord mobility (T2a) showed a statistically significant difference (OR, 1.83; 95% CI, 1.52-2.20; P < .001). Ultimate control after salvage surgery was reported in 7 studies, which also showed significantly better outcomes for T2a lesions over T2b lesions (OR, 1.90; 95% CI, 1.23-2.92; P = .005)., Conclusions: This meta-analysis indicates that impaired vocal cord mobility has a negative impact on local disease control and ultimate disease control in patients receiving primary radiotherapy for the treatment of T2 glottic carcinoma. We recommend that the subdivision of glottic cancer to T2a and T2b be reviewed and considered by the American Joint Committee on Cancer for inclusion in the Cancer Staging Manual.

The vasodilator response to bradykinin (BK) appears to be mediated by a number of different endothelium-derived relaxing factors (EDRFs). The EDRFs mediating the response depend on the species and vascular bed studied. The mechanism by which BK dilates the hindlimb vascular bed was investigated in the anesthetized rat. BK produced dose-dependent increases hindlimb blood flow. The NOS antagonist L-NAME had little effect on the magnitude of the increase in flow when baseline hemodynamic parameters were corrected by an NO donor infusion. However, the duration of the response was slightly shortened by L-NAME. Charybdotoxin (Chtx) and apamin nearly abolished the L-NAME resistant component of the hindlimb vasodilator response to BK, but did not affect the hindlimb vasodilator response to the sodium nitroprusside (SNP). The cyclooxygenase inhibitor meclofenamate and the K+-ATP channel blocker U37883A, in the presence of L-NAME, did not alter the vasodilator response to BK. These results suggest that a significant portion of the hindlimb vasodilator response to BK is mediated by the activation of KCa channels, and independent of NO synthesis, cyclooxygenase products, and activation of K+-ATP channels. The present data suggest that the mechanisms mediating the vasodilator response to BK in the hindlimb vascular bed of the rat are complex, consisting of a Chtx and apamin sensitive, L-NAME resistant phase and a minor phase mediated by NO. In contrast, NO accounts for about half of the hindlimb vasodilator response to acetylcholine (ACh), with the other half of the response mediated by a Chtx and apamin sensitive mechanism. Additionally, the present results demonstrate that the NO donor infusion technique is able to compensate for the loss of basal NO production following inhibition of NOS, and to restore hemodynamic parameters to pre-L-NAME levels, making it a useful technique for the investigation of the role of NO in mediating vascular responses.