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Background: Acute invasive fungal sinusitis (AIFS) is an aggressive disease that requires prompt diagnosis and multidisciplinary treatment given its rapid progression. However, there is currently no consensus on diagnosis, prognosis, and management strategies for AIFS, with multiple modalities routinely employed. The purpose of this multi‐institutional and multidisciplinary evidence‐based review with recommendations (EBRR) is to thoroughly review the literature on AIFS, summarize the existing evidence, and provide recommendations on the management of AIFS. Methods: The PubMed, EMBASE, and Cochrane databases were systematically reviewed from inception through January 2022. Studies evaluating management for orbital, non‐sinonasal head and neck, and intracranial manifestations of AIFS were included. An iterative review process was utilized in accordance with EBRR guidelines. Levels of evidence and recommendations on management principles for AIFS were generated. Results: A review and evaluation of published literature was performed on 12 topics surrounding AIFS (signs and symptoms, laboratory and microbiology diagnostics, endoscopy, imaging, pathology, surgery, medical therapy, management of extrasinus extension, reversing immunosuppression, and outcomes and survival). The aggregate quality of evidence was varied across reviewed domains. Conclusion: Based on the currently available evidence, judicious utilization of a combination of history and physical examination, laboratory and histopathologic techniques, and endoscopy provide the cornerstone for accurate diagnosis of AIFS. In addition, AIFS is optimally managed by a multidisciplinary team via a combination of surgery (including resection whenever possible), antifungal therapy, and correcting sources of immunosuppression. Higher quality (i.e., prospective) studies are needed to better define the roles of each modality and determine diagnosis and treatment algorithms. [ABSTRACT FROM AUTHOR]

Objectives: Manuka honey attacks biofilms, which contribute to bacterial persistence in cystic fibrosis sinusitis. The primary objective was to determine feasibility of investigating manuka honey as an irrigation treatment for cystic fibrosis sinusitis and secondarily to assess the treatment's preliminary effectiveness. Design: Prospective, single‐blinded (clinician only), randomised, parallel two‐arm pilot trial. Setting: Tertiary rhinology clinic. Participants: Subjects had recalcitrant cystic fibrosis sinusitis and previous sinus surgery. They received manuka honey or saline sinus irrigations twice daily for 30 days. Main Outcome Measures: Main outcomes were recruitment/retention rates and tolerability. Preliminary effectiveness was assessed based on quality‐of‐life Sinonasal Outcome Test‐22 and Lund‐Kennedy endoscopic change scores and post‐treatment culture negativity. Results: Over 10 months, 13 subjects were enrolled, and 77% (10/13) were included in the analysis. Manuka honey irrigations were well‐tolerated. The quality‐of‐life change score was clinically significant for manuka honey (−9 [−14,−6]) but not saline (−5 [−9,−1]), although the difference was not statistically significant (P =.29). Lund‐Kennedy endoscopic change score was significantly better for manuka honey (−3 [−5,−3]) versus saline (0 [0,0]) (P =.006). There was no difference in post‐treatment culture negativity between manuka honey (1/5, 20%) and saline (0/5, 0%) (P = 1.00). Conclusions: Manuka honey irrigations were well tolerated, and retention rates were high. Preliminary data showed that manuka honey achieved a clinically important difference in quality‐of‐life score and a significantly better endoscopic outcome. Microbiological control was difficult to achieve. A future definitive trial would require multi‐institutional recruitment. [ABSTRACT FROM AUTHOR]

Introduction: Management of pain following endoscopic sinus surgery (ESS) often involves intermittent use of opioid medications. Given the current opioid crisis, many surgeons aim to minimize opioid prescriptions. However, surgeons often avoid the use of NSAIDs following ESS out of concern for increased bleeding risk. We sought to evaluate the effectiveness and safety of over the counter dosing of ibuprofen on pain and bleeding rates following ESS. Methods: Prospective cohort pilot study of patients undergoing ESS. Patients self-selected either control arm (acetaminophen and PRN oxycodone) or intervention arm (alternating ibuprofen with acetaminophen, and PRN oxycodone). Outcome measures included pain (10-point visual analog scale [VAS]), bleeding rate (10-point VAS), and number of opiate pills consumed. Results: Thirty-nine patients completed the study (15 control and 24 intervention). Overall, patients in the intervention arm reported decreased pain levels at days 1 (−0.9 [95%CI: −2.2, 0.5], 3 (−0.9 [95%CI: −2.3, 0.5]), and 7 (−0.6 [95%CI: −1.8, 0.6]), as well as decreased postoperative bleeding at those same days −0.9 [95%CI: −2.1, 0.4], −0.9 [95%CI: −2.1, 0.4], and −0.7 [95% CI: −1.2, −0.7], compared to controls. Opiate consumption was similar between groups with patients consuming on average four opiate pills (oxycodone 5 mg). Conclusions: Over the counter dosing of ibuprofen along with acetaminophen may yield better pain control after sinus surgery compared to acetaminophen alone. Additionally, there was no significant difference in epistaxis in the ibuprofen cohort compared to the cohort who did not take ibuprofen. Furthermore, this study showed very few opioid pills were consumed after routine ESS regardless of pain regimen prescribed. A larger trial is needed to make definitive statements on safety and efficacy. Level of Evidence: 2b [ABSTRACT FROM AUTHOR]

Background: Chronic invasive fungal sinusitis (CIFS) is a rare, life‐threatening infection of the nose and sinuses. This study aims to identify factors that impact survival in 1 of the largest cohorts to date. Methods: Pathology records were reviewed for biopsy‐proven CIFS from 3 tertiary academic institutions from 1995 to 2016. Variables were analyzed using log‐rank survival analysis. Univariate Cox regression was performed at 1 and 12 months. Results: Thirty‐eight patients were included. Hematologic malignancy and diabetes were the most common underlying diseases (32% each). Aspergillus was the most common fungus (63%). Greater than 75% of the patients had an absolute neutrophil count (ANC) >1000 at the time of diagnosis. Overall survival at 1, 6, and 12 months was 89%, 68%, and 48%, respectively. In univariate analysis, factors associated with worse survival included: ANC <500 at 12 months (hazard ratio [HR] 4.8; p = 0.01), ANC <1000 at 12 months (HR 5.8; p = 0.001), and recent chemotherapy (HR 4; p = 0.01). The following factor was associated with improved survival in univariate analysis: ANC as a linear variable in the entire cohort (HR 0.7; p = 0.005). Conclusion: We present a multi‐institutional case‐series of CIFS and long‐term follow‐up. ANC <1000 at time of diagnosis and recent chemotherapy (within 1 month of diagnosis) are associated with poorer survival, whereas a rising ANC >1000 is associated with improved survival at 12 months. Further prospective studies are needed to further define factors that affect outcomes. [ABSTRACT FROM AUTHOR]

Background Manuka honey (MH) has been shown in vitro to be effective against biofilm-producing bacteria. This study assessed the effectiveness of MH for patients with active chronic rhinosinusitis (CRS) and prior sinus surgery. Methods This prospective single-blinded (clinician only) randomized controlled trial recruited patients with active CRS and prior sinus surgery. Patients received either MH or saline (SAL) sinus irrigations twice daily for 30 days and were offered oral antibiotics and/or oral/topical steroids as indicated. Outcomes were 22-item Sino-Nasal Outcome Test (SNOT-22) change score (primary), culture negativity, and Lund-Kennedy endoscopic change score. Results Forty-two patients were analyzed (MH, n = 20; SAL, n = 22). The SNOT-22 change score achieved a clinically significant improvement in both groups but was similar between MH (median [interquartile range]: −12 [−20, −1]) and SAL (−12.5 [−22, −6]) ( p = 0.57). Culture negativity was better on MH (8/19, 42%) compared to SAL (4/21, 19%), nearing statistical significance ( p = 0.11). Lund-Kennedy endoscopic change score improved in both groups but was not statistically better on MH (−3 [−5, 0]) compared to SAL (−1 [−2, 0]) ( p = 0.20). For patients not receiving oral antibiotics/steroids, culture negativity was statistically better on MH (5/10, 50%) compared to SAL (0/6, 0%) ( p = 0.04). MH was well-tolerated. No adverse events were reported. Conclusion In patients with active CRS and prior sinus surgery, both MH and SAL improved outcomes, but there was no statistically significant difference between these groups. However, in the subset that did not receive oral antibiotics/steroids, culture negativity was statistically better on MH, suggesting that MH alone may be effective for acute exacerbations of CRS. [ABSTRACT FROM AUTHOR]

Objective  Several different open and endoscopic approaches for the pterygomaxillary space and infratemporal fossa have been described. Limitations to these approaches include restricted exposure of the infratemporal fossa and difficult surgical manipulation. Study Design  Consecutive clinical cases utilizing a novel approach to access lesions in the infratemporal fossa and pterygomaxillary space were reviewed. Data was collected on pathology, lesion location, and surgical approach(es) performed. Computer modeling was performed to analyze the full extent of surgical access provided by the paramaxillary approach to the range of target locations. Results  Ten consecutive cases met inclusion criteria. Surgical access to the target lesion was achieved in all cases. Computer modeling of the approach derived the anatomical boundaries of the paramaxillary approach. Wide access to the posterior maxilla, and lateral or medial to the mandibular condyle allows for variability in endoscopic angles and access to more medial pterygomaxillary space lesions. The lateral extent is limited proximally only by the extent of cheek/soft tissue retraction and by the zygomatic arch more superiorly. The superior limit of dissection is at the temporal line. Conclusion  The endoscopic paramaxillary approach is a transoral minimally disruptive approach to the ITF and PS that provides excellent surgical exposure for resection of lesions involving these areas. Compared with previously described endoscopic approaches, there are no external incisions; tumor manipulation is straightforward without angled endoscopy, and all areas of the infratemporal fossa and pterygomaxillary space can be accessed. [ABSTRACT FROM AUTHOR]

Background: Patients with chronic rhinosinusitis (CRS) can experience cognitive dysfunction. The literature on this topic mostly reflects patient‐reported measurements. Our goal was to assess cognitive function in patients with CRS using objective measures, including saccadic eye movements—a behavioral response reflecting cognitive and sensory information integration that is often compromised in conditions with impaired cognition. Methods: Participants (N = 24 with CRS, N = 23 non‐CRS healthy controls) enrolled from rhinology clinic underwent sinonasal evaluation, quality of life assessment (Sino‐nasal Outcome Test 22 [SNOT‐22]), and cognitive assessment with the Neuro‐QOL Cognitive Function‐Short Form, the Montreal Cognitive Assessment (MoCA), and recording of eye movements using video‐oculography. Results: Participants with CRS were more likely to report cognitive dysfunction (Neuro‐QOL; 45.8% vs. 8.7%; p = 0.005) and demonstrate mild or greater cognitive impairment (MoCA; 41.7% vs. 8.7%; p = 0.005) than controls. Additionally, participants with CRS performed worse on the MoCA overall and within the executive functioning and memory domains (all p < 0.05) and on the anti‐saccade (p = 0.014) and delay saccade (p = 0.044) eye movement tasks. Poorer performance on the MoCA (r = −0.422; p = 0.003) and the anti‐saccade (r = −0.347; p = 0.017) and delay saccade (r = −0.419; p = 0.004) eye movement tasks correlated with worse CRS severity according to SNOT‐22 scores. Conclusion: This study is the first to utilize objective eye movement assessments in addition to researcher‐administered cognitive testing in patients with CRS. These patients demonstrated a high prevalence of cognitive dysfunction, most notably within executive functioning and memory domains, with the degree of dysfunction correlating with the severity of CRS. [ABSTRACT FROM AUTHOR]

Purpose Methods Results Conclusions Sinonasal malignancies (SNMs) adversely impact patients’ quality of life (QOL) and are frequently identified at an advanced stage. Because these tumors are rare, there are few studies that examine the specific QOL areas that are impacted. This knowledge would help improve the care of these patients.In this prospective, multi‐institutional study, 273 patients with SNMs who underwent definitive treatment with curative intent were evaluated. We used the University of Washington Quality of Life (UWQOL) instrument over 5 years from diagnosis to identify demographic, treatment, and disease‐related factors that influence each of the 12 UWQOL subdomains from baseline to 5 ‐years post‐treatment.Multivariate models found endoscopic resection predicted improved pain (vs. nonsurgical treatment CI 2.4, 19.4, p = 0.01) and appearance versus open (CI 27.0, 35.0, p < 0.001) or combined (CI 10.4, 17.1, p < 0.001). Pterygopalatine fossa involvement predicted worse swallow (CI −10.8, −2.4, p = 0.01) and pain (CI −17.0, −4.0, p < 0.001). Neck dissection predicted worse swallow (CI −14.8, −2.8, p < 0.001), taste (CI −31.7, −1.5, p = 0.02), and salivary symptoms (CI −28.4, −8.6, p < 0.001). Maxillary involvement predicted worse chewing (CI 9.8, 33.2; p < 0.001) and speech (CI −21.8, −5.4, p < 0.001) relative to other sites. Advanced T stage predicted worse anxiety (CI −13.0, −2.0, p = 0.03).Surgical approach, management of cervical disease, tumor extent, and site of involvement impacted variable UWQOL symptom areas. Endoscopic resection predicted better pain, appearance, and chewing compared with open. These results may aid in counseling patients regarding potential QOL expectations in their SNM treatment and recovery course. [ABSTRACT FROM AUTHOR]

Objective: To assess for differences in how patients and otolaryngologists define the term dizziness. Methods: Between June 2020 and December 2022, otolaryngology clinicians and consecutive patients at 5 academic otolaryngology institutions across the United States were asked to define the term "dizziness" by completing a semantics-based questionnaire containing 20 common descriptors of the term within 5 symptom domains (imbalance-related, lightheadedness-related, motion-related, vision-related, and pain-related). The primary outcome was differences between patient and clinician perceptions of dizzy-related symptoms. Secondary outcomes included differences among patient populations by geographic location. Results: Responses were obtained from 271 patients and 31 otolaryngologists. Patients and otolaryngologists selected 7.7 ± 3.5 and 7.1 ± 4.3 symptoms, respectively. Most patients (266, 98.2%) selected from more than 1 domain and 17 (6.3%) patients identified symptoms from all 5 domains. Patients and clinicians were equally likely to define dizziness using terms from the imbalance (difference, −2.3%; 95% CI, −13.2%, 8.6%), lightheadedness (−14.1%; −29.2%, 1.0%), and motion-related (9.4; −0.3, 19.1) domains. Patients were more likely to include terms from the vision-related (23.6%; 10.5, 36.8) and pain-related (18.2%; 10.3%, 26.1%) domains. There were minor variations in how patients defined dizziness based on geographic location. Conclusions: Patients and otolaryngologists commonly described dizziness using symptoms related to imbalance, lightheadedness, and motion. Patients were more likely to use vision or pain-related terms. Understanding of these semantic differences may enable more effective patient-clinician communication. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusions Patients with sinonasal malignancy (SNM) present with significant sinonasal quality of life (QOL) impairment. Global sinonasal QOL as measured by the 22‐item Sinonasal Outcomes Test (SNOT‐22) has been shown to improve with treatment. This study aims to characterize SNOT‐22 subdomain outcomes in SNM.Patients diagnosed with SNM were prospectively enrolled in a multi‐center patient registry. SNOT‐22 scores were collected at the time of diagnosis and through the post‐treatment period for up to 5 years. Multivariable regression analysis was used to identify drivers of variation in SNOT‐22 subdomains.Note that 234 patients were reviewed, with a mean follow‐up of 22 months (3 months–64 months). Rhinologic, psychological, and sleep subdomains significantly improved versus baseline (all p < 0.05). Subanalysis of 40 patients with follow‐up at all timepoints showed statistically significant improvement in rhinologic, extra‐nasal, psychological, and sleep subdomains, with minimal clinically important difference met between 2 and 5 years in sleep and psychological subdomains. Adjuvant chemoradiation was associated with worse outcomes in rhinologic (adjusted odds ratio (5.22 [1.69–8.66])), extra‐nasal (2.21 [0.22–4.17]) and ear/facial (5.53 [2.10–8.91]) subdomains. Pterygopalatine fossa involvement was associated with worse outcomes in rhinologic (3.22 [0.54–5.93]) and ear/facial (2.97 [0.32–5.65]) subdomains. Positive margins (5.74 [2.17–9.29]) and surgical approach—combined versus endoscopic (3.41 [0.78–6.05])—were associated with worse psychological outcomes. Adjuvant radiation (2.28 [0.18–4.40]) was associated with worse sleep outcomes.Sinonasal QOL improvements associated with treatment of SNM are driven by rhinologic, extra‐nasal, psychological, and sleep subdomains. [ABSTRACT FROM AUTHOR]

This article, published in the Journal of Neurological Surgery, explores the impact of endoscopic skull base surgery (ESBS) on sleep quality and cognitive function. The study conducted a retrospective cohort analysis of patients who underwent ESBS at an academic center. Patient-reported outcome measures were used to assess sleep quality and cognitive function before and after surgery. The results showed that patient-reported sleep quality worsened in the immediate postoperative period but improved over time. Cognitive function did not exhibit significant differences. The study suggests that factors such as anesthesia, hospitalization, and disrupted sleep patterns may contribute to sleep disturbance following ESBS. The findings have practical implications for preoperative counseling and managing patient expectations. [Extracted from the article]

Objective: To assess for differences of intended meaning in the description of congestion‐related symptoms among otolaryngology patients and clinicians. Materials and Methods: Between June 2020 and October 2022, a questionnaire consisting of 16 common descriptors of congestion‐related symptoms within four domains (obstructive‐related, pressure‐related, mucus‐related, and other symptoms) was completed by patients and otolaryngologists at five tertiary otolaryngology practices. The primary outcome was to assess differences in patient and clinician perceptions of congestion‐related symptoms. Differences based on geographic location was a secondary outcome. Results: A total of 349 patients and 40 otolaryngologists participated. Patients selected a median of 6.8 (standard deviation [SD] 3.0) terms compared with 4.0 (SD 1.6) terms for otolaryngologists (p < 0.001). Otolaryngologists were more likely to select obstruction‐related symptoms (difference 6.3%; 95% confidence interval [CI] 3.8%, 8.9%). Patients were more likely to describe congestion using pressure‐related (−43.7%; −58.9%, −28.5%), mucus‐related (−43.5%; −59.3%, −27.8%), and other symptoms (−44.2; −51.3%, −37.1%) compared with otolaryngologists. There were no significant differences identified based on geographic location with regard to symptom domains on multivariate analysis. Conclusions: There are differences between otolaryngologists and their patients in the interpretation of the symptoms of congestion. Clinicians tended to have a narrower interpretation of congestion that was limited to the obstruction‐related symptom domain, while patients defined congestion more broadly. This has important counseling and communication implications for the clinician. [ABSTRACT FROM AUTHOR]

Background: Quality of life (QOL) for individuals with sinonasal malignancy (SNM) is significantly under‐studied, yet it is critical for counseling and may impact treatment. In this study we evaluated how patient, treatment, and disease factors impact sinonasal‐specific and generalized QOL using validated metrics in a large cohort over a 5‐year posttreatment time frame. Methods: Patients with SNM who underwent definitive treatment with curative intent were enrolled in a prospective, multisite, longitudinal observational study. QOL was assessed using the 22‐item Sino‐Nasal Outcome Test (SNOT‐22) and University of Washington Quality of Life Questionnaire (UWQOL) instruments at pretreatment baseline and multiple follow‐ups through 5 years posttreatment. Multivariable modeling was used to determine demographic, disease, and treatment factors associated with disease‐specific and generalized physical and social/emotional function QOL. Results: One hundred ninety‐four patients with SNM were analyzed. All QOL indices were impaired at pretreatment baseline and improved after treatment. SNOT‐22 scores improved 3 months and UWQOL scores improved 6 to 9 months posttreatment. Patients who underwent open compared with endoscopic tumor resection had worse generalized QOL (p < 0.001), adjusted for factors including T stage. Pterygopalatine fossa (PPF) involvement was associated with worse QOL (SNOT‐22, p < 0.001; UWQOL Physical dimension, p = 0.02). Adjuvant radiation was associated with worse disease‐specific QOL (p = 0.03). Neck dissection was associated with worse generalized physical function QOL (p = 0.01). Positive margins were associated with worse generalized social/emotional function QOL (p = 0.01). Conclusion: Disease‐specific and generalized QOL is impaired at baseline in patients with SNM and improves after treatment. Endoscopic resection is associated with better QOL. PPF involvement, adjuvant radiation, neck dissection, and positive margins were associated with worse QOL posttreatment. [ABSTRACT FROM AUTHOR]

Background: The Cavernous Hemangioma Exclusively Endonasal Resection (CHEER) staging system has become the gold standard for outcomes reporting in endoscopic orbital surgery for orbital cavernous hemangiomas (OCHs). A recent systematic review demonstrated similar outcomes between OCHs and other primary benign orbital tumors (PBOTs). Therefore, we hypothesized that a simplified and more comprehensive classification system could be developed to predict surgical outcomes of other PBOTs. Methods: Patient and tumor characteristics as well as surgical outcomes from 11 international centers were recorded. All tumors were retrospectively assigned an Orbital Resection by Intranasal Technique (ORBIT) class and stratified based on surgical approach as either exclusively endoscopic or combined (endoscopic and open). Outcomes based on approach were compared using chi‐squared or Fisher's exact tests. The Cochrane‐Armitage test for trend was used to analyze outcomes by class. Results: Findings from 110 PBOTs from 110 patients (age 49.0 ± 15.0 years, 51.9% female) were included in the analysis. Higher ORBIT class was associated with a lower likelihood of gross total resection (GTR). GTR was more likely to be achieved when an exclusively endoscopic approach was utilized (p < 0.05). Tumors resected using a combined approach tended to be larger, to present with diplopia, and to have an immediate postoperative cranial nerve palsy (p < 0.05). Conclusion: Endoscopic treatment of PBOTs is an effective approach, with favorable short‐term and long‐term postoperative outcomes as well as low rate of adverse events. The ORBIT classification system is an anatomic‐based framework that effectively facilitates high‐quality outcomes reporting for all PBOTs. [ABSTRACT FROM AUTHOR]

Objective: Describe a novel treatment approach to a rare bony neoplasm in the frontal sinus. Study Design: Case report. Methods: Retrospective chart review of an osteoblastoma of the frontal sinuses complicated by a right orbital mucocle. Demographic, endoscopic, radiographic, pathologic, and surgical data were collected for synthesis and review. MEDLINE, Embase, and Cochrane databases were searched from 1977 to 2017 to review publications of surgical management of frontal sinus neoplasms. Results: A single female patient with a large frontal sinus osteoblastoma was successfully treated with a bilateral transorbital and transnasal approach. The right orbital mucocele was marsupialized into the frontal sinus. Gross total resection of the tumor was achieved, with complete resolution of the presurgical morbidity. The surgery was tolerated well without iatrogenic injury or sequela. Conclusion: Frontal sinus osteoblastoma is a rare condition. Complete surgical excision is considered curative. Various endoscopic and open approaches have been described. Here we show the feasibility and efficacy of a multiportal strategy in the successful management of a large frontal sinus osteoblastoma complicated by a right orbital mucocele. [ABSTRACT FROM AUTHOR]

Background: Surgical skill development outside the operating room aims to improve technique and subsequent patient safety. The purpose of this study was to evaluate the correlation between technical and cognitive skills with cadaveric endoscopic sinus surgery (ESS) performance and change in ESS performance before and after implementation of a dedicated ESS simulation‐based and knowledge‐based curriculum. Methods: A before‐after study design was implemented among 10 medical students and 10 junior otolaryngology residents. Participants completed a knowledge‐based, multiple‐choice ESS pretest and watched an ESS prosection video. Participants performed 9 tasks on a previously validated low‐cost, low‐technology, nonbiologic sinus surgery task trainer followed by cadaveric maxillary antrostomy and anterior ethmoidectomy. Participants then completed a simulation‐based and knowledge‐based ESS curriculum followed by a repeat cadaveric maxillary antrostomy and anterior ethmoidectomy. Performance was graded with a 5‐point global rating scale (GRS) and a 5‐point ESS‐specific checklist. Results: We observed a stronger correlation between the multiple‐choice, knowledge‐based, ESS pretest scores and cadaveric ESS GRS score (r = 0.73) than between task trainer performance and cadaveric ESS GRS score (r = 0.43). We also noted a significant increase in precurriculum vs postcurriculum mean ± standard deviation (SD) cadaveric ESS checklist scores for both medical students (1.18 ± 0.25 vs 2.58 ± 0.57; p = 0.0002) and residents (2.09 ± 0.78 vs 2.88 ± 0.54; p = 0.023). The greatest improvements for residents were in performance of uncinectomy, enlargement of maxillary os, and identification of the bulla. Conclusion: These findings provide evidence supporting the use of ESS training curricula outside the operating room. [ABSTRACT FROM AUTHOR]

Introduction: Sinus infections are a common reason patients seek medical care. However, the intended meaning of the term sinus infection among patients and otolaryngologists is incompletely understood. Methods: In this multi‐institutional cross‐sectional study, a semantics‐based questionnaire was provided to consecutive patients presenting to otolaryngology clinics at six academic centers from June 2020 until May 2021. The primary outcome was respondent definitions for sinus infection from a list of 28 proposed terms covering six general categories. Secondary outcome measures included differences between geographic regions. Results: Responses were obtained from 560 patients (54% female, mean age 48.9 years) and 29 otolaryngologists (42% female, mean age 37.4 years). Patients and otolaryngologists selected a median of 10 and 11 terms, respectively, to define a sinus infection. Among patients the most frequently selected symptom categories were mucus (500, 89.3%), pressure/pain (480, 85.7%), and airflow (468, 83.6%). Compared to patients, clinicians selected with greater frequency the symptom categories of pressure/pain (14.3% difference; 95% CI, 7.6% to 22.5%), mucus (10.7% difference; 95% CI, 4.7% to 18.3%) and airflow (13.0% difference; 95% CI, 4.8% to 21.7%). Multiple categories were selected by 96% of patients and 100% of providers. Conclusion: The definition of sinus infection appears variable for both patients and otolaryngologists, though patients appear to apply a broader range of symptoms to the term sinus infection. There were no pronounced geographic differences in the description of a sinus infection in this US sample population. Patients commonly described sinus infection in the context of pain‐related symptoms. Appreciation of these semantic differences may enable more effective patient‐clinician communication. [ABSTRACT FROM AUTHOR]

Background: We describe the surgical technique for use of small intestine submucosal (SIS) xenograft implant for inferior turbinate reconstruction and report our early results in a pilot case series of patients suffering from symptoms consistent with empty nose syndrome (ENS). Methods: We report an observational prospective cohort study of ENS patients undergoing inferior turbinate reconstruction using porcine SIS xenograft. Effects of the procedure on quality of life (QOL) were assessed through serial 25-itemSino-NasalOutcome Test (SNOT-25) scores and analyzed by 1-way analysis of variance (ANOVA) between the initial visit and 1, 4, and 12 weeks after surgery. Results: Three patients with ENS underwent inferior turbinate reconstruction. No unexpected complications were noted over the 12-week follow-up course. Despite mild partial reabsorption of the SIS implant, neoturbinates were maintained in all patients. The mean preoperative score SNOT-25 was 77.6 (maximum 125). The mean postoperative scores were 65 at 1 week, 57 at 4 weeks, and 55 at 12 weeks (p<0.01). Furthermore, for the "difficulty with nasal breathing" and "nose is too open" subdomains, statistically significant improvement was also noted at weeks 4 and 12 postoperatively (p < 0.05 and p <0.01, respectively). Conclusion: The use of porcine SIS xenograft for inferior turbinate reconstruction appears to be safe and effective in the treatment of patients diagnosed with ENS. This study demonstrates statistically significant improvement in global QOL metrics and nasal-specific subdomains following inferior turbinate reconstruction/neoturbinate creation for ENS as evaluated through serial SNOT-25 scores. [ABSTRACT FROM AUTHOR]

A healthy man in his 30s presented with a 2-week history of severe bitemporal pain and pressure. He was initially treated for presumed acute rhinosinusitis, but his symptoms continued to worsen and underwent endoscopic sinus surgery at an outside community facility. He developed left abducens nerve palsy postoperatively, and magnetic resonance imaging (MRI) demonstrated evidence of extensive skull base osteomyelitis. He was initiated on intravenous (IV) broad-spectrum antibiotics but was subsequently found to have prostatic and submandibular sterile fluid collections. The patient subsequently developed new right abducens and left vagal nerve palsies and underwent revision endoscopic sinus surgery. Pathology revealed extensive inflammation, necrotizing granulomas, and evidence of small and medium vessel vasculitis. Extensive laboratory workup was negative, except for anti-PR-3 antibody positivity. Given the characteristic findings on pathology and laboratory findings, the patient was diagnosed with granulomatosis with polyangiitis (GPA). High-dose glucocorticoid therapy as well as rituximab infusion were promptly initiated. He had marked improvement in his symptoms and resolution of his right CN VI palsy but left-sided CN VI and CN X palsies persisted. This patient presented without the typical rhinologic manifestations of GPA, and rather presented with progressive sinusitis, skull base osteomyelitis with associated cranial neuropathies, and aseptic systemic abscesses. Prompt diagnosis of GPA is particularly important in those with otorhinolaryngological manifestations, as early initial immunosuppressive therapy has been linked to lower relapse and mortality rates. Vigilance and early differentiation between GPA and other forms of sinusitis is of critical importance, particularly when symptoms are refractory to standard rhinosinusitis therapies. [ABSTRACT FROM AUTHOR]

Objectives: Topical vasoconstrictors and intravenous tranexamic acid (IV TXA) are safe and efficacious to decrease bleeding and improve the surgical field during endoscopic sinus surgery (ESS). The purpose of this study was to investigate practice patterns, awareness of clinical evidence, and comfort levels among anesthesia providers regarding these hemostatic agents for ESS. Methods: A total of 767 attending anesthesiologists, residents, and certified registered nurse anesthetists (CRNAs) at 5 United States academic centers were invited to participate in a survey regarding their experience with IV TXA and 3 topical vasoconstrictor medications (oxymetazoline, epinephrine, and cocaine) during ESS. Results: 330 (47%) anesthesia providers responded to the electronic survey. 113 (97%) residents, 92 (83%) CRNAs, and 52 (68%) attendings managed 5 or fewer ESS cases per month. Two-thirds of providers had not reviewed efficacy or safety literature for these hemostatic agents. Oxymetazoline was perceived safest, followed by epinephrine, IV TXA, and cocaine. Respondents considered potential side effects over surgical field visibility when selecting agents. The majority of providers had no formal training on these agents for ESS, but indicated interest in educational opportunities. Conclusion: Many anesthesia providers are unfamiliar with safety and efficacy literature regarding agents used to improve hemostasis for ESS, highlighting a need for development of relevant educational resources. Rhinologic surgeons have an opportunity to communicate with anesthesia colleagues on the use of hemostatic agents to improve the surgical field during ESS. [ABSTRACT FROM AUTHOR]

Introduction  Paranasal sinus mucoceles result from obstruction of mucous glands resulting in a cystic fluid collection that expands and encroaches upon surrounding structures. Transnasal endoscopic marsupialization has largely replaced open resection. However, mucoceles located in the orbital region or the lateral frontal sinus continue to be difficult to approach via the transnasal approach alone and often require additional approaches, such as the frontal trephine. This study sought to investigate the feasibility of the transorbital technique as an adjunct to traditional transnasal approaches in the management of paranasal sinus mucoceles. Methods  A retrospective case series of paranasal sinus mucoceles approached with a transorbital technique from a tertiary care center. Results  From 2008 to 2016, 17 patients were treated with a transorbital approach for 20 mucoceles. Of note, 24% of the patients in our series had undergone previous surgical management of the mucocele (nontransorbital approach), representing revision cases. Most mucoceles involved the frontal sinus (82%). The total complication rate was 6%. We observed no new or worsened diplopia, ptosis, or permanent visual loss. Recurrence rate was 6%. Conclusions  The endoscopic transorbital approach is a feasible complement to transnasal approaches for treatment of mucoceles located in technically challenging locations. We have demonstrated that transorbital approaches can be performed with no resultant orbital damage, visual change, ptosis, or permanent diplopia. While most patients can be treated with a standard transnasal approach, the transorbital approach can be used as part of a multiportal strategy for those with difficult to access mucoceles. Future prospective studies are needed to further characterize patient selection and outcomes. [ABSTRACT FROM AUTHOR]

Background: Acute invasive fungal sinusitis (AIFS) is a rare, aggressive infection occurring in immunocompromised patients. In this study we examined factors that affect survival in AIFS, and whether immune‐stimulating therapies (IST) improve survival. Methods: Pathology records of biopsy‐proven AIFS were reviewed from 3 academic institutions from 1995 to 2016. Univariate and multivariate Cox regressions were performed at 1 and 3 months from diagnosis. Results: One hundred fourteen patients were included; 45 received IST. In the univariate analysis, the following factors were associated with worse survival: hematologic malignancy (3‐month hazard ratio [HR], 3.7; p = 0.01); recent chemotherapy (within 1 month of AIFS diagnosis) (3‐month HR, 2.3; p = 0.02); recent bone marrow transplant (BMT) (3‐month HR, 2.5; p = 0.02); and infection with atypical fungi (1‐month HR, 3.1; p = 0.04). The following were associated with improved survival in univariate analysis: increasing A1c% (1‐month HR, 0.7; p = 0.01) and surgical debridement (1‐month HR, 0.1; p = 0.001). One third of patients with a hematologic malignancy had an absolute neutrophil count (ANC) >1000 at the time of diagnosis. ANC was not associated with prognosis in these patients. The following were associated with worse survival in multivariate analyses: hematologic malignancy; recent chemotherapy; atypical organisms; and cavernous sinus extension. In multivariate analyses, IST was associated with a 70% reduction in mortality at 1 month (p = 0.02). Conclusion: We presented the largest series of AIFS. Further studies are needed to examine the importance of ANC in diagnosis and prognosis. Patients diagnosed with atypical organisms may be at higher risk of death. IST likely improves short‐term survival, but prospective studies are needed. [ABSTRACT FROM AUTHOR]

Background Most existing objective surgical motion analysis schemes are limited to structured surgical tasks or recognition of motion patterns for certain categories of surgeries. Analyzing instrumentmotion data with respect to anatomical structures can break the limit, and an anatomical region segmentation algorithm is required for the analysis. Methods An atlas was generated by manually segmenting the skull base into nine regions, including left/right anterior/posterior ethmoid sinuses, frontal sinus, left and right maxillary sinuses, nasal airway, and sphenoid sinus. These regions were selected based on anatomical and surgical significance in skull base and sinus surgery. Six features, including left and right eye center, nasofrontal beak, anterior tip of nasal spine, posterior edge of hard palate at midline, and clival body at foramen magnum, were used for alignment. The B-spline deformable registration was adapted to fine tune the registration, and bony boundaries were automatically extracted for final precision improvement. The resultant deformation field was applied to the atlas, and themotion data were clustered according to the deformed atlas. Results Eight maxillofacial computed tomography scans were used in experiments. One was manually segmented as the atlas. The others were segmented by the proposed method. Motion data were clustered into nine groups for every dataset and outliers were filtered. Conclusions The proposed algorithm improved the efficiency of motion data clustering and requires limited human interaction in the process. The anatomical region segmentations effectively filtered out the portion of motion data that are out of surgery sites and grouped them according to anatomical similarities. [ABSTRACT FROM AUTHOR]