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Obstructive sleep apnea (OSA) is a systemic disease that is due to upper airway collapse and obstruction during sleep, resulting in frequent hypoxia, sympathetic overdrive, tachycardia, nocturnal hypertension, and oxidative metabolic stress. Daytime symptoms include unrefreshed sleep, daytime tiredness, loss of memory, irritability, lack of concentration, poor work productivity, poor quality of life (QOL), mood swings, and even depression; nighttime symptoms include loud snoring, choking at night, gasping for air, frequent arousals, witnessed apneas, and nocturia. OSA can lead to systemic diseases like hypertension, cardiovascular events, myocardial infarct, and fatal arrhythmias. The “gold” standard test for OSA is commonly assigned as the level I overnight polysomnography (PSG). However, sleep specialists are aware of its shortcomings and the inconsistencies of the single parameter AHI (apnea-hypopnea index). It is widely known that there is discordance between AHI (that is used to denote outcomes/success of therapy) and real actual clinical outcomes such as QOL, patient perception of disease, cardiovascular measures, and/or survival. Recent studies have shown that the use of a single parameter AHI is inaccurate, inadequate, and unrealistic; sleep medicine needs to be more holistic to assess actual clinical treatment outcomes. As OSA is a systemic disease that affects all the end organs, outcome parameters should be those related to these end organ effects; some of these more holistic parameters (SLEEP GOAL) include snoring level, sleep latency, execution time, Epworth sleepiness scale, blood pressure, gross weight (BMI), oxygen duration below 90%, AHI, and QOL scores.

BackgroundEvaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA). MethodsUsing previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus. ResultsThe ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated. ConclusionThis review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Objective Does nasal surgery affect multilevel surgical success outcome. Methods Prospective eight country nonrandomized trial of 735 obstructive sleep apnea (OSA) patients, who had multilevel palate and/or tongue surgery, divided into two groups, with or without nose surgery. Results There were 575 patients in nose group, 160 patients in no nose group. The mean age for nose group 44.6 ± 11.4, no nose group 44.2 ± 11.8. Mean preoperative BMI for nose group 27.5 ± 3.6, no nose group 27.5 ± 4.1, mean postoperative BMI nose group 26.3 ± 3.7, no nose group 27.1 ± 3.8 (P = .006). Mean preoperative AHI nose group 32.7 ± 19.4, no nose group 34.3 ± 25.0 (P = .377); and mean postoperative AHI nose group 13.5 ± 10.2, no nose group 17.1 ± 16.0 (P = .001). Mean preoperative ESS nose group was 11.3 ± 4.7, no nose group was 10.4 ± 5.4 (P = .051); and mean postoperative ESS nose group was 5.3 ± 3.2, no nose group was 6.7 ± 2.8 (P = .001). The nose group had higher percentage change (adjusted for age, gender, BMI) in AHI (33.7%, 95% CI 14% to 53.5%) compared to the no nose group (P = .001); the nose group also had more percentage change in ESS (37%, 95% CI 23.6% to 50.3%) compared to the no nose group (P

As health care expenditures rise, novel ways to increase efficiency are sought. The operating room (OR) represents an area where there is opportunity to optimize work flow and supply use. Evidence suggests that instrument redundancy in the OR tends to be high and that direct cost savings can be achieved by "optimizing" surgical trays. The purpose of this study was to quantify the potential time savings associated with surgical tray optimization.Instrument utilization was reviewed for 4 procedures: tonsillectomy, sinus surgery, septoplasty, and septorhinoplasty. Instruments used in20% of cases were excluded. Data on tray assembly time in the central processing department and instrument setup time in the OR were prospectively collected over a 3-month period before and after tray optimization. Student'sTray assembly times were found to be significantly shorter following optimization, with percentage reduction in time ranging from 58% to 66% (Tray optimization may reduce stress and adverse events and allow managers to better estimate staffing requirements. Cost-benefits could not be determined given a limited understanding of how departments choose to redistribute time savings.Measurable and significant time savings can be achieved by assessing instrument utilization rates and reducing tray redundancy, leading to lower performance variability and improved efficiency.

OBJECTIVES/HYPOTHESIS Our objective was to determine whether drug-induced sleep apnea (DISE) affects the successfulness of the surgical outcome. STUDY DESIGN Prospective, seven-country, nonrandomized trial. METHODS There were 326 consecutive obstructive sleep apnea (OSA) patients who had nose, palate, and/or tongue surgery included in the study. DISE was performed in only one group. RESULTS There were 170 patients in the DISE group and 156 patients in no-DISE group. The mean preoperative body mass index (BMI) for the DISE group was 27.6 ± 4.6, whereas in the no-DISE group it was 28.1 ± 3.9 (P = .23). The mean preoperative systolic blood pressure (SBP) for the DISE group was 130.4 ± 16.7, whereas in the no-DISE group it was 142.9 ± 15.5 (P < .001). The mean preoperative diastolic blood pressure (DBP) for the DISE group was 81.4 ± 9.7, whereas in the no-DISE group it was 89.1 ± 9.7 (P < .001). The mean preoperative apnea-hypopnea index (AHI) for the DISE group was 32.6 ± 18.8, whereas in the no-DISE group it was 33.7 ± 19.6 (P = .61). The mean postoperative AHI for the DISE group was 15.9 ± 12.6, whereas in the no-DISE group it was 13.2 ± 8.8 (P = .023). The age-, gender-, BMI-adjusted percentage change in AHI for the DISE group was -48.4 ± 31.9, whereas in the no-DISE group it was -59.8 ± 18.6 (P < .001). The age-, gender-, and BMI-adjusted success rate for the DISE group was 66.5%, whereas in the no-DISE group it was 80.8% (P = .004). The age-, gender-, and BMI-adjusted change in SBP for the DISE group was -6.1 ± 8.6, whereas in the no-DISE group it was -13.3 ± 11.1 (P < .001). The age-, gender-, and BMI-adjusted change in DBP in the DISE group was -5.2 ± 12.1, whereas in the no-DISE group it was -12.4 ± 11.7 (P < .001). The mean age- and gender-adjusted change in BMI for the DISE group was -4.6 ± 12.9, whereas in the no-DISE group it was -6.3 ± 18.5 (P = .34). The Cohen effect of BMI on the overall AHI, lowest oxygen saturation, and blood pressure changes was 0.08. CONCLUSIONS DISE may not significantly affect surgical success in OSA. LEVEL OF EVIDENCE 2c Laryngoscope, 130:551-555, 2020.

OBJECTIVES/HYPOTHESIS To evaluate the impact of adenotonsillectomy for pediatric sleep-disordered breathing (SDB) on parental sleep quality, daytime sleepiness, and child quality of life. STUDY DESIGN Prospective cohort study. METHODS Pediatric patients aged 2 to 10 years with SDB and suspected obstructive sleep apnea (OSA) requiring adenotonsillectomy were identified at a single tertiary-care pediatric otolaryngology hospital. Parental daytime sleepiness and quality of sleep were evaluated pre- and postoperatively using the Epworth Sleepiness Scale (ESS) and Pittsburg Sleep Quality Index (PSQI), respectively. Child quality of life, in the context of suspected OSA, was evaluated by the Obstructive Sleep Apnea Quality of Life Survey (OSA-18), pre- and postoperatively. Paired-samples t tests were conducted to analyze data. RESULTS Forty-seven patients with a mean (standard deviation [SD]) age of 4.9 (2.2) years, participated. Mean (SD) parental age was 35.5 (4.6) years. Statistically significant decreases of 2.1 points were observed between preoperative and postoperative parental mean global ESS (P = .007; 95% confidence interval [CI]: 0.6-3.6) and mean total PSQI (P = .001; 95% CI: 0.9-3.1) scores. A statistically significant improvement (41.6 points) was observed between preoperative and postoperative on mean OSA-18 scores (P < .0001; 95% CI: 35.7-47.6). CONCLUSIONS Adenotonsillectomy performed in the pediatric population for SDB, with suspected OSA, can positively impact parental daytime sleepiness and sleep quality in addition to pediatric quality of life. LEVEL OF EVIDENCE 2 Laryngoscope, 130:232-237, 2020.

Background Aspirin-exacerbated respiratory disease (AERD) is characterized by eosinophilic rhinosinusitis, nasal polyposis, and bronchial asthma, along with the onset of respiratory reactions after the ingestion of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetylsalicylic acid (ASA). In addition to the therapeutic routines and surgical options available, a low dietary intake of food salicylate has been suggested as adjunctive therapy for this condition. This study aimed to assess the influence of a short-term low salicylate diet on inflammatory markers in patients with AERD and whether that would result in symptomatic improvement. Methods Prospective study with randomization to either a high or low salicylate diet for 1 week, followed by cross-over to the other study arm. Participants were asked to record their dietary salicylate for each week of the study. Urinary creatinine, salicylate and leukotriene levels were measured at the time of recruitment, end of week one and end of week two and the SNOT-22 questionnaire was filled out at the same time points. Results A total of seven participants completed the study. There was no statistical difference in the urinary salicylate and leukotriene levels between the two diets; nevertheless, participants on low salicylate diet reported improved SNOT-22 symptoms scores (p = 0.04), mainly in the rhinologic, ear/facial, and sleep dysfunction symptom domains. In addition, these last two domains outcomes were more significant than the minimal clinically important difference. Conclusions A short-term low salicylate diet may not result in biochemical outcomes changes but seems to provide significant symptomatic relief for patients with AERD. Trial registration NCT01778465 (www.clinicaltrials.gov) Graphical abstract

Background The SARS-CoV-2 (COVID) pandemic has resulted in an increase in virtual care. While some specialties are well suited to virtual care, Otolaryngology – Head and Neck Surgery could be limited due to reliance on physical examination and nasal endoscopy, including Rhinology. It is likely virtual care will remain integrated for the foreseeable future and it is important to determine the strengths and weaknesses of this treatment modality for rhinology. Methods A survey on virtual care in rhinology was distributed to 61 Canadian rhinologists. The primary objective was to determine how virtual care compared to in-person care in each area of a typical appointment. Other areas focused on platforms used to deliver virtual care and which patients could be appropriately assessed by virtual visits. Results 43 participants responded (response rate 70.5%). The majority of participants use the telephone as their primary platform. History taking and reviewing results (lab work, imaging) were reported to be equivalent in virtual care. Non-urgent follow up and new patients were thought to be the most appropriate for virtual care. The inability to perform exams and nasal endoscopy were reported to be significant limitations. Conclusion It is important to understand the strengths and limitations of virtual care. These results identify the perceived strengths and weaknesses of virtual care in rhinology, and will help rhinologists understand the role of virtual care in their practices. Graphical abstract

Purpose To perform a needs assessment of epistaxis first-aid measures practiced by family physicians and Emergency Department (ED) staff in London, Ontario, Canada. Methods Paper-based multiple-choice questionnaires were distributed to participants. Participant recruitment was conducted in two parts: 1) 28 Emergency Medicine (EM) attending physicians, 21 resident physicians training in the ED, and 26 ED nurses were surveyed while on duty in the ED; 2) 27 family physicians providing walk-in or urgent care and attending a continuing medical education (CME) event were also surveyed. Respondents were asked to identify where to apply compression to the nose and how patients should be positioned during acute epistaxis. Results Regarding where to apply compression, 19% of family physicians, 43% of EM physicians, 24% of residents, and 8% of ED nurses responded correctly. Regarding positioning, all groups responded similarly with 54–62% responding correctly. Twenty-one percent of emergency physicians, 19% of residents, 11% of family physicians, and 4% of nurses responded correctly to both questions. Conclusions Most family physicians, EM attending physicians, ED nurses, and residents could not correctly identify basic first-aid measures for acute epistaxis. This study identifies an area where knowledge is lacking and the potential for improvement in patient management and education. Grapical Abstract

Background Recent evidence suggests that biologic therapy with targeted activity within the Type 2 inflammatory pathway can improve the clinical signs and symptoms of chronic rhinosinusitis with nasal polyposis (CRSwNP). There remains a population in CRSwNP that despite medical therapy and endoscopic sinus surgery have persistent signs and symptoms of disease. Therefore, biologics, monoclonal antibody agents, could be beneficial therapeutic treatments for these patients. There have been eight randomized, double-blind, placebo-controlled trails performed for CRSwNP targeted components of the Type 2 inflammatory pathway, notably interleukin (IL)-4, IL-5 and IL-13, IL-5R, IL-33, and immunoglobulin (Ig)E. However, there are no formal recommendations for the optimal use of biologics in managing Chronic Rhinosinusitis (CRS) within the Canadian health care environment. Methods A Delphi Method process was utilized involving three rounds of questionnaires in which the first two were completed individually online and the third was discussed on a virtual platform with all the panelists. 17 fellowship trained rhinologists across Canada evaluated the 28 original statements on a scale of 1–10 and provided comments. A rating within 1–3 indicated disagreement, 8–10 demonstrated agreement and 4–7 represented being neutral towards a statement. All ratings were quantitively reviewed by mean, median, mode, range and standard deviation. Consensus was defined by removing the highest and lowest of the scores and using the “3 point relaxed system”. Results After three rounds, a total of 11 statements achieved consensus. This white paper only contains the final agreed upon statements and clear rationale and support for the statements regarding the use of biologics in patients with CRS. Conclusion This white paper provides guidance to Canadian physicians on the use of biologic therapy for the management of patients with CRS, but the medical and surgical regimen should ultimately be individualized to the patient. As more biologics become available and additional trials are published we will provide updated versions of this white paper every few years. Graphical abstract

IntroductionChronic rhinosinusitis (CRS) is common, with a Canadian prevalence of 5%, and associated with significant morbidity. Understandably, CRS impairs workplace productivity but that productivity substantially increases following surgical treatment. CRS with nasal polyps (CRSwNP), the most common type of CRS, is usually treated with a combination of medications and endoscopic sinus surgery (ESS). Historically, surgical treatment has only been performed in the operating room at a cost of about $C3500. However, recent studies have shown that a de-escalated procedure, endoscopic polypectomy performed in clinic (EPIC), can provide an improvement in patient symptoms to levels equal to those for ESS. Moreover, EPIC has additional proposed advantages including shorter recovery time, significantly lower cost to the healthcare system and shorter wait time for the patient. There is currently insufficient evidence to draw conclusions about the superiority of polypectomy or ESS for the management of CRSwNP.Methods and analysisWe designed a multicentre, open-label, randomised controlled trial to evaluate whether EPIC was non-inferior to the current clinical standard, ESS for the treatment of CRSwNP. The primary outcome is the Sinonasal Outcome Test-22 score measured at baseline and at 3 months after surgery. Other outcomes include peak nasal inspiratory flow, quality of life measured by the EuroQoL 5 Dimensions 5 Levels questionnaire and work impairment using the Work Productivity and Activity Impairment Questionnaire.We aim to recruit 140 patients from sites across Canada. Participants will be randomly assigned to EPIC or ESS and followed up for 3 months in clinic after the procedure. Additionally, participants will enter a 5-year long-term follow-up period.Ethics and disseminationThis study was approved by the Ottawa Health Sciences Network Research Ethics Board for all sites in Ontario, Canada (study number CTO0801). Sites located outside of Ontario obtained approval from their local/institutional research ethics board.Trial registration numberNCT02975310.

Non-Hodgkin lymphoma (NHL) is a hematological malignancy that can sometimes originate from the nasal cavities and paranasal sinuses. Patients who present with these tumors typically report sinonasal symptoms. However, a diagnostic challenge can arise when a patient's primary complaints include unique complex symptoms limited to the contralateral side of the tumor. This report describes the case of an 83-year-old man who presented to our center with a left-sided mass and right-sided proptosis with vision loss. After a nasal biopsy was taken, the patient was referred to the ophthalmology department to diagnose the cause of his ocular symptoms, which were not believed to be related to the mass. When biopsy results later returned as diffuse large B-cell lymphoma (DLBCL), an emergent repeat biopsy following lymphoma protocol was performed to confirm the diagnosis. A CT scan of the head and orbits showed generalized enlargement of the right optic nerve and extraocular muscles, and a positron emission tomography (PET) scan showed increased 18F-fluorodeoxyglucose (FDG) uptake in the right ethmoid sinus and orbit. The left-sided mass and right-sided symptoms resolved simultaneously with chemotherapy. This is the first documented case of a sinonasal mass causing ocular symptoms exclusively on the contralateral side. The presented diagnostic challenge highlights the importance of thorough investigations.

Healthcare services in many countries have been partially or completely disrupted by the Coronavirus (COVID-19) pandemic since its onset in the end of 2019. Amongst the most impacted are the elective medical and surgical services in order to conserve resources to care for COVID-19 patients. As the number of infected patients decrease across Canada, elective surgeries are being restarted in a staged manner. Since Otolaryngologists – Head & Neck Surgeons manage surgical diseases of the upper aerodigestive tract where the highest viral load reside, it is imperative that these surgeries resume in a safe manner. The aim of this document is to compile the current best evidence available and provide expert consensus on the safe restart of rhinologic and skull base surgeries while discussing the pre-operative, intra-operative, and post-operative care and tips. Risk assessment, patient selection, case triage, and pre-operative COVID-19 testing will be analyzed and discussed. These guidelines will also consider the optimal use of personal protective equipment for specific cases, general and specific operative room precautions, and practical tips of intra-operative maneuvers to optimize patient and provider safety. Given that the literature surrounding COVID-19 is rapidly evolving, these recommendations will serve to start our specialty back into elective rhinologic surgeries over the next months and they may change as we learn more about this disease.

BackgroundTopical cocaine is favoured by many surgeons for sinonasal surgery due to its superior vasoconstrictive and anesthetic properties. However, historical reports suggesting cocaine is associated with an increased risk of cardiac events have led many surgeons to turn to alternative topical medications. The objective of this study was to determine whether cocaine use during sinonasal surgery is associated with an increased risk of perioperative cardiac events and death.MethodsWe conducted a population-based analysis of patients undergoing sinonasal surgery from 2009-2016 using linked administrative health care data sets in Ontario, Canada. We compared patients treated at institutions that primarily use topical cocaine (exposed group) to those treated at institutions that do not use cocaine (unexposed group). Our primary outcome was a composite of major cardiac events or all-cause mortality within 48 hours of surgery. Due to low event rates, the outcome was compared using a Fisher's exact test.ResultsOf 10,549 patients who were included in the study, 27.4% were treated at an institution that uses topical cocaine. The rate of the composite of perioperative major cardiac event or all-cause mortality within 48 hours of surgery in the exposed and unexposed groups was, ≤0.2% and 0 (p-value>0.05), respectively.ConclusionsIn this large real-world cohort of patients undergoing sinonasal surgery, there does not appear to be any significant increased risk of morbidity or mortality associated with cocaine use. These findings have important implications for surgeons performing this procedure.

Background Endoscopic skull base surgery continues to evolve in its indications, techniques, instrumentation, and postoperative care. As surgery of the skull base will often violate dura, intraoperative and postoperative cerebrospinal fluid (CSF) leak is not uncommon and represents a potential conduit for air and bacterial contamination. Patients with obstructive sleep apnea (OSA) requiring continuous positive airway pressure (CPAP) therapy undergoing skull base surgery represent a challenging group. However, there appears to be a paucity of consensus regarding the postoperative management of this patient population. The objective of this study is to examine practice patterns and expert opinion on the use of postoperative CPAP and nasal saline in patients with OSA. Methods A 14-item survey was generated by consensus among expert authors and distributed online to members of the North American Skull Base society and other international skull base community members. Data were analyzed for median, mean, and standard deviation variables. Subgroup analysis was completed between surgeons from different geographical locations and operative experience. SPSS22 was utilized for all complex statistical analysis and figures. Results Seventy-one responses were collected from skull base surgeons. In patients with OSA, respondents would resume patients’ CPAP therapy after a mean of 10.1 days (median, 7; standard deviation [SD], 10.2), without a CSF leak. In the presence of a small CSF leak, the mean duration would increase to 14.3 days (median, 14; SD, 9.8) and to 20.7 days (median, 21; SD, 11.8) in the presence of a larger leak. A surgeon’s choice to attribute the relationship between delaying the start of nasal saline and CPAP after the endoscopic skull base surgery with progressively more challenging skull base repair was found to be statistically significant ( P Conclusion Saline and CPAP therapies are initiated after the endoscopic skull base surgical repairs by surgeons at an increasing temporal delay in relation to the degree and complexity of the skull base defect repaired.

Systematic review of palate surgery for the treatment of OSA. Independent searches to identify publications relevant to OSA treatment and upper airway palate surgery. All relevant studies published between January 2001 and February 2018 were included. Inclusion criteria were adult patients, documented airway evaluation methods and absent hypopharyngeal collapse. Outcomes included success rates of treatment, AHI, Epworth scale, QOL and snoring VAS. Fifty-nine papers with a total of 2715 patients, UPPP accounted for 16.7% of all the procedures. Evident differentiation progressing from 2001 to 2018, from 2001 to 2010, the percentage of UPPP procedures were 25.67%, from 2011 to 2018, there were only 12.6% of UPPP procedures. The average follow up was 8.18 months. Meta-analysis on the AHI change for all procedures, showed the fixed effect AHI per follow-up (FU) month change was 1.45 (95% CI 1.33, 1.8), p

Objective 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). Study Design Basic science computer model generation. Methods 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. Results Computer simulation predictions for percentage of airway collapse and site of maximal collapse show agreement with observed results seen on endoscopic visualization. Conclusion Modeling the upper airway in OSA patients is feasible and holds promise in aiding patient-specific surgical treatment. Level of Evidence NA. Laryngoscope, 2017

Objectives/Hypothesis To evaluate if upper airway surgery reduces blood pressure in patients with obstructive sleep apnea (OSA). Study Design Prospective series. Methods A prospective series of 112 consecutive OSA patients with hypertension (HTN). All patients were > 18 years old, respiratory disturbance index >5, all levels of apnea-hypopnea index (AHI), with a history of HTN treated with medication for at least 6 months. Surgical procedures included septoplasty, turbinate reduction, palate surgery, and tongue base reduction. Results There were 92 men and 20 women, with a mean age of 48.6 years, mean body mass index (BMI) was 27.5 (range, 19.7–34.7). Mean follow-up was 16.1 months. The mean preoperative AHI was 32.6 (range, 1.2–104), with the mean lowest oxygen saturation (LSAT) of 79.9% (range, 52%–93%). The mean adjusted preoperative and postoperative systolic blood pressure (SBP) was reduced from 146 ± 15.3 mm Hg to 122 ± 12.5 mm Hg (P

OBJECTIVEEndoscopic resection of pituitary adenomas has been reported to improve vision function in up to 80%–90% of patients with visual impairment due to these adenomas. It is unclear how these reported rates translate into improvement in visual outcomes and general health as perceived by the patients. The authors evaluated self-assessed health-related quality of life (HR-QOL) and vision-related QOL (VR-QOL) in patients before and after endoscopic resection of pituitary adenomas.METHODSThe authors prospectively collected data from 50 patients who underwent endoscopic resection of pituitary adenomas. This cohort included 32 patients (64%) with visual impairment preoperatively. Twenty-seven patients (54%) had pituitary dysfunction, including 17 (34%) with hormone-producing tumors. Patients completed the National Eye Institute Visual Functioning Questionnaire and the 36-Item Short Form Health Survey preoperatively and 6 weeks and 6 months after surgery.RESULTSPatients with preoperative visual impairment reported a significant impact of this condition on VR-QOL preoperatively, including general vision, near activities, and peripheral vision; they also noted vision-specific impacts on mental health, role difficulties, dependency, and driving. After endoscopic resection of adenomas, patients reported improvement across all these categories 6 weeks postoperatively, and this improvement was maintained by 6 months postoperatively. Patients with preoperative pituitary dysfunction, including hormone-producing tumors, perceived their general health and physical function as poorer, with some of these patients reporting improvement in perceived general health after the endoscopic surgery. All patients noted that their ability to work or perform activities of daily living was transiently reduced 6 weeks postoperatively, followed by significant improvement by 6 months after the surgery.CONCLUSIONSBoth VR-QOL and patient's perceptions of their ability to do work and perform other daily activities as a result of their physical health significantly improved by 6 months after endoscopic resection of pituitary adenoma. The use of multidimensional QOL questionnaires provides a precise assessment of perceived outcomes after endoscopic surgery.

Objective: Published research in obstructive sleep apnea (OSA) appears limited despite OSA being a highly prevalent adult and pediatric disease leading to many adverse outcomes if left untreated. We aimed to quantify the deficit in OSA scientific literature in order to provide a novel way of identifying gaps in knowledge and a need for further research inquiry. Methods: This was a Bibliometric analysis study. Using Ovid Medline database we analyzed and compared research output (medical and surgical) between adult OSA and similarly prevalent chronic conditions (Type II diabetes (T2DM), coronary artery disease (CAD) and osteoarthritis (OA)) from December 2016 up to fifty years prior. Linear graphs were utilized to trend collected data. Utilizing same strategy, we compared publication trends for pediatric OSA to asthma and gastroesophageal reflux (GER). Results: Adult OSA publications (n = 9314) were significantly underrepresented when compared to T2DM (n = 66,023), CAD (n = 31,526) and OA (n = 34,123). Linear plots demonstrated that despite increasing number of publications this disparity persisted annually. Surgical literature composed 10.4% (n = 972) of adult OSA publications and reached a plateau in the last ten years. Pediatric OSA (n = 2994) had less research output when compared to asthma (n = 47,442) and GER (n = 6705). However, over past five years pediatric OSA surpassed GER in annual number of publications. Surgical literature represented 23.1% (n = 693) of pediatric OSA publications and continued increasing over past ten years. Study methodologies for both adult and pediatric OSA showed a lack of randomized controlled trials and meta-analyses in comparison to other diseases. Conclusion: Our review shows substantial deficit in total, annual and surgical adult OSA published research compared to similarly prevalent diseases. This trend is not entirely observed in pediatric OSA literature. Keywords: Obstructive sleep apnea, Pediatrics, Sleep medicine, Diabetes mellitus type 2, Asthma, Coronary artery disease, Osteoarthritis, Sleep disordered, Breathing, Gastroesophageal reflux, Bibliometric analysis

Objective 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. Data Sources MEDLINE, EMBASE, and Scopus databases. Review Methods 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. Results 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. Conclusion 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

Background In the field of otolaryngology, oral corticosteroids (OCS) are widely prescribed for rhinosinusitis. Although there is evidence in the literature regarding specific OCS dosing protocols, it is not known to what extent these recommendations are being followed. Objective To examine the current state of OCS prescribing habits for rhinosinusitis by American Rhinologic Society members. Methods An anonymous online survey was sent to all American Rhinologic Society members. Dosing, frequency, tapering, and overall prescribing habits for OCS were assessed in chronic rhinosinusitis with polyposis (CRSwP) and in chronic rhinosinusitis without polyposis and acute bacterial rhinosinusitis. The CRSwP group was subdivided into aspirin-exacerbated respiratory disease, allergic fungal sinusitis, and not otherwise specified. Results were compared with current guidelines. Descriptive statistics were used to analyze data. Results Ninety-three surveys were completed (response rate, 12.9%). Prednisone was the most common OCS prescribed. In the CRSwP-aspirin-exacerbated respiratory disease group (n = 86), the median starting dose was 60 mg (range, 4-80 mg) and the average duration was 8 days (range, 2-28 days). In the CRSwP-allergic fungal sinusitis group (n = 81), the median starting dose was 50 mg (range, 20-60 mg), and the average duration was 6 days (range, 2-35 days). In the CRSwP-not otherwise specified group (n = 84), the median starting dose was 50 mg (range, 20-80 mg) and the average duration was 5 days (range, 1-21 days). OCS were prescribed for chronic rhinosinusitis without polyposis and acute bacterial rhinosinusitis by 66.0 and 62.4% of respondents, respectively. Conclusion Significant heterogeneity existed in OCS prescribing habits for rhinosinusitis. Discrepancies were observed between survey results and evidence-based recommendations. Developing standardized OCS treatment protocols for rhinosinusitis may improve the quality of care by optimizing clinical outcomes and reducing the risk of complications.

Patient-specific finite element (FE) modeling of the upper airway is an effective tool for accurate assessment of obstructive sleep apnea (OSA) syndrome. It is also useful for planning minimally invasive surgical procedures under severe OSA conditions. A major requirement of FE modeling is having reliable data characterizing the biomechanical properties of the upper airway tissues, particularly oropharyngeal soft tissue. While some data characterizing this tissue's linear elastic regime is available, reliable data characterizing its hyperelasticity is scarce. The aim of the current study is to estimate the hyperelastic mechanical properties of the oropharyngeal soft tissues, including the palatine tonsil, soft palate, uvula, and tongue base. Fresh tissue specimens of human oropharyngeal tissue were acquired from 13 OSA patients who underwent standard surgical procedures. Indentation testing was performed on the specimens to obtain their force–displacement data. To determine the specimens' hyperelastic parameters using these data, an inverse FE framework was utilized. In this work, the hyperelastic parameters corresponding to the commonly used Yeoh and 2nd order Ogden models were obtained. Both models captured the experimental force-displacement data of the tissue specimens reasonably accurately with mean errors of 11.65% or smaller. This study has provided estimates of the hyperelastic parameters of all upper airway soft tissues using fresh human tissue specimens for the first time.

OBJECTIVES/HYPOTHESIS To investigate long-term complications of newer reconstructive palate surgery techniques. STUDY DESIGN Retrospective case-series analysis. METHODS Retrospective six-country clinical study of OSA patients who had nose and palate surgery. RESULTS There were 217 patients, mean age = 43.9 ± 12.5 years, mean body mass index = 25.9 ± 4.7, mean preoperative apnea-hypopnea index [AHI] = 30.5 ± 19.1, follow-up 41.3 months. A total of 217 palatal procedures were performed, including 50 expansion sphincter pharyngoplasties (ESP), 34 functional expansion pharyngoplasties (FEP), 40 barbed reposition pharyngoplasties (BRP), 64 modified uvulopalatopharyngoplasties (mUPPP), 11 uvulopalatal flap procedures (UPF), nine suspension pharyngoplasties (SP), eight relocation pharyngoplasties (RP), and one z-pharyngoplasty (ZPP). Complications included were constant and/or felt twice per week; dry throat (7.8%), throat lump feeling (11.5%), throat phlegm (10.1%), throat scar feeling (3.7%), and difficulty swallowing (0.5%). Of the 17 patients who had a dry throat complaint, two were constant (one SP, one RP), 15 were occasional (10 mUPPP, three SP, two BRP). Of the 25 patients with the throat lump feeling, four were constant (three RP, one ZPP), 21 were occasional (10 mUPPP, five SP, five UPF, one BRP). Of the 22 patients with the throat phlegm feeling, four were constant (two SP, two RP), 18 were occasional (10 mUPPP, four BRP, two FEP, two SP). Of the eight patients with throat scar feeling, eight were occasional (four SP, two mUPPP, one FEP, one RP), none were constant. One patient had difficulty swallowing (RP procedure). There was no velopharyngeal incompetence, taste disturbance, nor voice change. Highest symptom complaints were mUPPP, SP, and RP, whereas the lowest symptom complaint was ESP. CONCLUSIONS Newer palatal techniques have shown to have less long-term complications compared to the older ablative techniques. LEVEL OF EVIDENCE 4 Laryngoscope, 130:2281-2284, 2020.

Objective To evaluate multilevel palate and tongue base surgery as a method of treatment of obstructive sleep apnea by comparing the pre- and postoperative apnea-hypopnea index. Methods We conducted a systematic review. MEDLINE and Embase databases were searched in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for conducting systematic reviews. Two authors screened all articles and performed methodological quality assessment. Relevant articles where reviewed in detail. Standard inclusion criteria were applied for article selection. Relevant data were extracted and summarized, a difference of means random-effects model was performed. Our primary outcome measure was change in apnea-hypopnea index pre-/postsurgical treatment. Results Of 1,172 studies identified from January 2006 to March 2017, 46 studies met inclusion criteria and were included in the systematic review. This included 11 surgical subgroups and 1,806 patients. Methodological quality and risk of bias assessments were completed. There was strong male predominance 86.8 (standard deviation [SD] = 10.3%), and the average age was 46.8 (SD = 4.0) years. All studies included overweight to obese patients (average body mass index = 29.1 [SD = 3.5]). The average preoperative apnea-hypopnea index was 39.0 (SD = 15.4), and the average postoperative apnea-hypopnea index decreased to 18.3 (SD = 7.5). Meta-analysis data yielded a decrease in apnea-hypopnea index of -23.67 with a 95% confidence interval of -27.27 to -20.06. Conclusions Non-maxillomandibular advancement, multilevel surgical procedures for obstructive sleep apnea demonstrate significant improvements in reduction of apnea-hypopnea index following surgery in addition to improvement in many other sleep-specific outcomes. Future research should include larger, higher-level studies that compare surgical treatments and identify factors associated with outcomes. Level of evidence NA Laryngoscope, 129:1712-1721, 2019.

Background Cocaine has traditionally been the topical decongestant most frequently used for visualization of the surgical field in Endoscopic Sinus Surgery (ESS). Alternatives include xylometazoline, oxymetazoline, and epinephrine. The understanding of the safety profile of each agent is changing, as are the practices of Otolaryngologists-Head & Neck Surgeons. The objective of this study is to determine decongestant use practices in ESS across Canada, which has not previously been studied. Methods A cross-sectional survey design using a 24-item electronic questionnaire was distributed to actively practicing members of the Canadian Society of Otolaryngology-Head and Neck Surgery via email. A French translated version of the survey was also available. Questions explored the respondents’ demographics and decongestion practices for ESS. Results Ninety-six surveys from otolaryngologists practicing in Canada were completed (19% response rate). The average time in practice was 16.5 years (range 1–50 years, SD 12.0 years). Twenty-six (27%) of respondents use some form of cocaine solution for topical decongestion in ESS. Over a total of over 1500 combined practice-years, eight respondents (8%) personally experienced an adverse event that could be attributed to cocaine, including two mortalities. One cardiac even was directly attributable to the patients’ use of recreational cocaine in the immediate pre-operative period. Conclusion The popularity of cocaine for topical decongestion in ESS in present-day Canada is less than in surveys from other countries. However, there are few reported adverse events with long-term consequences that are attributable to intraoperative cocaine. Considering the beneficial effects of cocaine for visualization and pain control, this change in practice warrants further investigation. Electronic supplementary material The online version of this article (10.1186/s40463-019-0337-8) contains supplementary material, which is available to authorized users.

Objectives/hypothesis To evaluate a possible regrowth of lingual tonsil lymphatic tissue in patients submitted to lingual tonsil resection with transoral robotic surgery (TORS). Study design Retrospective Study. Methods Medical records of patients surgically treated by means of TORS to remove excessive lymphatic tissue of the lingual tonsil were retrospectively reviewed. Postoperative endoscopic data after long-term follow-up were analyzed to investigate possible lymphatic tissue regrowth. Preoperative and postoperative lingual tonsil lymphatic tissue were classified according to the standardized Friedman's grading scale ranging from 0 to 4. Results Sixty-eight patients (41 male and 27 female; mean age = 51.3 years) were considered suitable for the study analysis. Clinical regrowth was observed in six (8.8%) patients: four (5.9%) and two (2.9%) patients with grade 2 and 3 lymphatic hypertrophy, respectively. No correlation between the grade of regrowth, the time interval from surgery, and the volume of lymphatic tissue removed was found. Conclusions The lymphatic tissue regrowth after TORS resection appears to be very low. Level of evidence 4 Laryngoscope, 129:2652-2657, 2019.

I read the interviews regarding wait times in the Canadian health care system[1][1] with great interest, but also with a sense of disappointment. For all the proposals made by the interviewees to improve wait times, the glaringly obvious one of taking surgical care outside of the hospital was not

Background 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. Methods 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 population >18 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. Results 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. Conclusion 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).

The typical patient with obstructive sleep apnea (OSA) suffers from frequent nocturnal hypoxemia, sympathetic overdrive, tachycardia, nocturnal hypertension, oxidative metabolic stress, and unrefreshed sleep. These patients subsequently have daytime somnolence, poor memory, irritability, poor concentration, low work productivity, hypertension, mood swings, and even depression. These affect the OSA patient’s entire quality of life (QOL) and mental state. The gold standard diagnostic test for OSA is overwhelmingly cited as the overnight polysomnography (PSG). During the overnight polysomnogram, the frequency of obstructive events is reported as the apnea-hypopnea index (AHI); the severity of the OSA is deemed and based on the number of apnea and hypopnea events per hour. As consequence the effectiveness of each and/or combined surgical interventions for OSA is almost exclusively based on the reported changes in AHI post-operatively, again, from the polysomnogram; moreover, based on a specific arbitrarily assigned reduction in AHI (50 % reduction) and an AHI below 15 commonly known as the Sher criteria. However, recent evidence has shown that there is a consistent discordance between the levels of AHI used to denote outcomes/success of therapy and real-world clinical outcomes such as QOL, patient perception of disease, cardiovascular measures, and/or survival. Moreover, in many areas of medicine patient-reported outcome measures (PROM) and QOL assessments are gaining substantial traction as priority items to assess when gauging effect of therapy for all manner of diseases, yet in the case of OSA the AHI remains paradoxically persistent as the main, and frequently the only, outcome measure reported in the vast majority of surgical and non-surgical OSA studies in the literature. How success at therapy is measured when treating OSA needs re-evaluation in light of this evidence, and we propose SLEEP GOAL as a more appropriate means of doing so.

Background 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. Methods 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, or >7 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). Results 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 the >7-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. Conclusion 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 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. Methods 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]). Results 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), p < 0.001; NSSS: 3 (95% CI, 1.75 to 4), p < 0.001; ACQ-7: 4.5 (95% CI, 1.5 to 8.5), p < 0.001; POSE 6 (95% CI, 2.5 to 10), p < 0.001; and LKES: 2.5 (95% CI, 1.5 to 4), p < 0.001). Conclusion 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.

Background When prearranged standard surgical trays contain instruments that are repeatedly unused, the redundancy can result in unnecessary health care costs. Our objective was to estimate potential savings by performing an economic evaluation comparing the cost of surgical trays with redundant instruments with surgical trays with reduced instruments ("reduced trays"). Methods We performed a cost-analysis from the hospital perspective over a 1-year period. Using a mathematical model, we compared the direct costs of trays containing redundant instruments to reduced trays for 5 otolaryngology procedures. We incorporated data from several sources including local hospital data on surgical volume, the number of instruments on redundant and reduced trays, wages of personnel and time required to pack instruments. From the literature, we incorporated instrument depreciation costs and the time required to decontaminate an instrument. We performed 1-way sensitivity analyses on all variables, including surgical volume. Costs were estimated in 2013 Canadian dollars. Results The cost of redundant trays was $21 806 and the cost of reduced trays was $8803, for a 1-year cost saving of $13 003. In sensitivity analyses, cost savings ranged from $3262 to $21 395, based on the surgical volume at the institution. Variation in surgical volume resulted in a wider range of estimates, with a minimum of $3253 for low-volume to a maximum of $52 012 for high-volume institutions. Interpretation Our study suggests moderate savings may be achieved by reducing surgical tray redundancy and, if applied to other surgical specialties, may result in savings to Canadian health care systems.

Background This report presented the case of a difficult-to-remove needle foreign body. The patient had a dental procedure in which a 30-gauge needle was lost in the gingival buccal sulcus. Several attempts at removal were unsuccessful. The patient presented to the otolaryngology clinic with trismus, pain with mastication, intermittent right otalgia, and numbness of the right cheek. Methods The needle was finally localized in the infratemporal fossa and removed by using image guidance technology. Results This case demonstrated an approach to a difficult-to-locate foreign body removal and the importance of intraoperative imaging in foreign body localization. Conclusion Foreign bodies of the infratemporal fossa and posterior orbit are better removed via endoscopic than open technique.

Aims To report visual acuity outcomes and potential complications in patients undergoing endoscopic transnasal orbital decompression in the setting of acutely deteriorating sight secondary to dysthyroid optic neuropathy (DON) unresponsive to corticosteroid therapy. No previous reports describe vision outcomes in this specific patient population undergoing urgent endoscopic decompression. Material and methods Retrospective case review at a tertiary-care academic hospital. Four patients with DON were identified that underwent urgent endoscopic orbital decompression for acutely deteriorating vision. Three patients underwent a later decompression of the other orbit, yielding seven decompressions in total for acutely deteriorating vision. Operative technique entailed inferior and medial wall decompressions. The posterior limit of medial wall decompression was within the sphenoid, just anterior to the annulus of Zinn to fully decompress the optic nerve. Primary outcome was visual acuity. Results In all seven decompressions, visual acuity improved substantially. In 5/7 eyes, preoperative vision was severely impaired at 20/150 or worse. Two eyes had mild and moderate impairment at 20/50 and 20/100. Post-operatively, the moderately and severely impaired eyes improved to 20/60 or better. No complications were encountered. Conclusion Transnasal endoscopic orbital decompression is a safe, effective treatment for acutely worsening visual loss from DON. All cases demonstrated significant objective improvement in visual acuity. Given the need for later contralateral decompression in 3 patients, consideration should be given to performing bilateral orbital decompressions at the time of surgery.

We read with interest the piece by Laratta and colleagues[1][1] regarding diagnosis and treatment of obstructive sleep apnea in adults. The authors are to be commended for the thoughtfulness of their work. However, we are concerned by several important omissions from this piece. First, although the

Finite element (FE)-based biomechanical simulations of the upper airway are promising computational tools to study abnormal upper airway deformations under obstructive sleep apnea (OSA) conditions and to help guide minimally invasive surgical interventions in case of upper airway collapse. To this end, passive biomechanical properties of the upper airway tissues, especially oropharyngeal soft tissues, are indispensable. This research aimed at characterizing the linear elastic mechanical properties of the oropharyngeal soft tissues including palatine tonsil, soft palate, uvula, and tongue base. For this purpose, precise indentation experiments were conducted on freshly harvested human tissue samples accompanied by FE-based inversion schemes. To minimize the impact of the probable nonlinearities of the tested tissue samples, only the first quarter of the measured force-displacement data corresponding to the linear elastic regime was utilized in the FE-based inversion scheme to improve the accuracy of the tissue samples’ Young's modulus calculations. Measured Young's moduli of the oropharyngeal soft tissues obtained in this study are presented. They include first estimates for palatine tonsil tissue samples while measured Young's moduli of other upper airway tissues were obtained for the first time using fresh human tissue samples.