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Although surgical lasers were introduced to the field of otolaryngology more than 20 years ago, their use in rhinologic surgery has remained relatively limited. With the development of the holmium:yttrium-aluminum-garnet (YAG) laser, a device is now available that offers those features necessary for effective sinus surgery:precise bone ablation, efficient soft tissue coagulation, and fiberoptic transmission. This solid-state laser of 2.1-microns wavelength can be coupled with endoscopic instrumentation for the surgical treatment of sinus disease. This study was conducted to determine the clinical efficacy of the holmium:YAG laser for endoscopic sinus surgery. A microscopic analysis of laser-treated sinus tissue was also performed in an attempt to determine the histologic basis of the observed clinical findings. In a prospective, randomized, controlled, single-blinded study, 32 consecutive patients underwent endoscopic sinus surgery using the holmium:YAG laser on one side of the nose and conventional endoscopic instrumentation on the other side. Patients rated symptoms for each side of the nose at 1 week, 1 month, 3 months, 6 months, and 2 years after surgery. Healing parameters were similarly rated by the surgeon. Until the study was completed, patients were not told which side of the nose had been treated with laser surgery. No intraoperative complications occurred. The mean intraoperative blood loss was 24.6 mL less on the laser-treated side of the nose than on conventionally treated side (P < .001). At 1 week after surgery, there was increased mucosal edema on the laser-treated side (P < .01). Crust formation was greater on the conventionally treated side at 1 week and was greater on the laser-treated side at 1 mouth (P < .01). Improvements in symptoms of pain, congestion, and drainage were equivalent for both treatment modalities (P < .001). Microscopic analysis demonstrated the ability of the holmium:YAG laser to remove tissue in relatively thin layers with ablation depths of 260 +/- 8.2 microns, 286 +/- 9.4 microns, and 341 +/- 20.4 microns per pulse at energy levels of 0.5, 1.0, and 1.5 J, respectively. A zone of thermal necrosis extending up to 1 mm beyond the site of laser impact was thought to correlate with the increased postoperative edema observed on the laser-treated side. Endoscopic sinus surgery with the holmium:YAG laser is as effective as nonlaser techniques in relieving the symptoms of chronic sinusitis. Laser surgery offers improved intraoperative hemostasis, but it causes increased postoperative tissue edema. The holmium:YAG laser provides the surgeon with an additional tool for the performance of safe, effective sinus surgery. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: Intraoperative guidance systems have been developed which use infrared tracking technology to assist with anatomical localization during sinus surgery. Although the introduction of this technology is intended to increase the safety and efficacy of sinus surgery, little is known about its actual impact in the clinical setting. The objective of this report was to study the application and utilization of an image guidance system shared by multiple sinus surgeons in a specialty hospital. Study Design: Combined prospective case study and retrospective analysis of physician surveys. Methods: An optical-based image guidance system (LandmarX, Xomed, Inc., Jacksonville, FL) was used by 34 physicians to perform 754 sinonasal surgeries over a 2.5-year period at Massachusetts Eye and Ear Infirmary. In 19 cases, system registration was repeated during surgery to measure the effect of fiducial placement on system accuracy. Results: The measured accuracy of anatomical localization at the start of surgery (mean value, 1.69 +/- 0.38 mm) was comparable to the perceived accuracy of 1 to 3 mm that was reported by 79% of surgeons surveyed. Operating room time (mean period, 130.6 +/- 41.1 min) correlated with the surgical procedure performed (P < .05), but not with the disease stage or revision rate. According to a majority of surgeons, use of the image guidance equipment increased operating room time by 15 to 30 minutes during initial cases and by 5 to 15 minutes once experience with the equipment had been acquired. More than 90% of surgeons anticipated their continued use of the image guidance equipment for sinus surgery at a similar or greater level in the future. Conclusion: An optical-based image guidance system can be successfully integrated into a multisurgeon operating room environment. Use of the system provides accurate anatomical localization during sinus surgery and results in a relatively high level of physician satisfaction. [ABSTRACT FROM AUTHOR]

Background: No widely accepted, validated instrument currently exists to measure clinical outcomes in patients who undergo dacryocystorhinostomy (DCR) for treatment of epiphora., Objective: To develop a patient-reported outcome measure applicable to this population., Methods: Psychometric evaluations, consultation with experts, and review of the literature informed item generation of a 12-question questionnaire to incorporate the most relevant symptoms experienced by patients with nasolacrimal duct obstruction. This questionnaire, known as the Tearing Assessment and Rating Scale-12 (TEARS-12), was administered to 32 patients before and after intervention, in the form of endoscopic DCR. Statistical analysis was performed to measure internal consistency, responsiveness, and test-retest reliability., Results: Pre-operative and post-operative TEARS-12 scores (28.2 [standard error (SE) 3.19] vs 11.8 [SE 3.25], respectively, P  = 0.001) demonstrated improved patient outcome within 6 weeks following endoscopic DCR. Cronbach's alpha for the questionnaire was 0.90, indicating high overall reliability. Additionally, each question demonstrated internal reliability, with a corrected item-total correlation greater than 0.30. The intraclass correlation between the two pre-operative scores was 0.858 ( P  < 0.001), indicating high test-retest reliability., Conclusion: TEARS-12 is a statistically valid, easy-to-administer instrument to measure clinical outcomes in patients who undergo endoscopic DCR., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: The EuroQol 5-Dimension (EQ-5D) is a general health survey that is quick to administer, widely used, and directly convertible to health utility values (HUV). We aim to describe the five-year EQ-5D outcomes among patients who undergo surgical treatment for chronic rhinosinusitis (CRS)., Study Design: Prospective observational cohort study., Methods: Patients with CRS completed the EQ-5D questionnaire preoperatively and annually for five years following endoscopic sinus surgery. Paired t-tests and McNemar's tests were used to compare preoperative and postoperative scores. Mixed-effects modeling was used for multivariate analysis., Results: Among 1296 patients enrolled in our study, 812 (74.7%) completed the postoperative survey at one year and 336 (38.9%) completed it at five years. There was a significant and sustained reduction of patients reporting pain/discomfort (74.9% vs. 58.0%, p < 0.001) and anxiety/depression (49.6% vs. 38.1%, p = 0.01) out to five years. Frequency of problems reported in the usual activity domain decreased at one year and was sustained through year four (30.6% vs 19.7%, p = 0.003). After multivariable modeling, female gender (p = 0.02), prior sinus surgery (p = 0.01), tobacco use (p = 0.038), headaches (p = 0.013), allergies (p = 0.001), diabetes (p = 0.022), hypertension (p = 0.036), higher preoperative SNOT-22 score (p < 0.001), and a lower preoperative Lund-Mackay score (p < 0.001) were associated with significantly worse EQ-5D HUV over time. Similarly, a worse EQ-5D Visual Analog Scale (VAS) over time was associated with allergies (p = 0.03), diabetes (p < 0.001), hypertension (p = 0.04), higher preoperative SNOT-22 score (p < 0.001), and prior sinus surgery (p < 0.001)., Conclusion: Patients with chronic rhinosinusitis experience significant sustained improvements in health-related quality of life up to five years after ESS as measured by the EQ-5D instrument., Level of Evidence: Level 2 Laryngoscope, 134:2592-2601, 2024., (© 2023 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To identify the impact of gender on the clinical outcomes of endoscopic sinus surgery (ESS) through the comparison of quality of life measures in female and male patients who undergo surgical treatment for chronic rhinosinusitis (CRS)., Study Design: Prospective observational cohort study., Methods: Patients with CRS completed the 22-item Sino-Nasal Outcome Test (SNOT-22) and EuroQol 5-Dimension Survey (EQ-5D) preoperatively and annually for 5 years following ESS. Health utility values (HUV) were calculated from EQ-5D scores. Comparisons of cohort characteristics were performed with chi-square and t-tests. A multivariable linear mixed effects model evaluated changes in SNOT-22 and HUV over time by gender., Results: Among the 1268 patients (54% female) enrolled, 789 and 343 completed postoperative surveys at one and 5 years, respectively. Preoperatively, females experienced more severe symptoms: mean SNOT-22 score (51.1 ± 20.9 female vs. 44.7 ± 20.0 male, p < 0.001) and HUV (0.80 ± 0.14 female vs. 0.84 ± 0.11 male, p < 0.001). These gender differences were resolved by year one postoperatively (SNOT-22: p = 0.083; HUV: p = 0.465). Two years after surgery, however, females reported more severe symptoms (SNOT-22: 25.6 ± 20.7 female vs. 21.5 ± 17.4 male, p = 0.005; HUV: 0.88 ± 0.12 female vs. 0.90 ± 0.11 male, p = 0.018), a difference that persisted at year five. These gender-related differences remained after adjusting for age, race, ethnicity, nasal polyps, history of prior ESS, and smoking status (p < 0.001). Within-subject improvement was comparable between genders (SNOT-22: p = 0.869; HUV: p = 0.611)., Conclusion: Females with CRS reported more severe symptoms both before and 5 years after surgery compared to their male counterparts. Understanding the mechanism behind these gender-related differences is important for optimizing CRS treatment., Level of Evidence: 2 Laryngoscope, 133:3319-3326, 2023., (© 2023 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Currently, limited data exist as to long-term disease-specific outcomes after endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS). In this report, we present outcomes data collected over 5 years in a large prospective cohort of patients who underwent surgical treatment for CRS., Methods: Patients who completed the 22-item Sino-Nasal Outcome Test (SNOT-22) before ESS were asked to complete the same survey at yearly intervals for 5 years thereafter. The impact of patients' demographics and clinical characteristics on clinical outcome was measured using mixed effects modeling for univariate and multivariable analysis. Multivariable logistic regression threshold analyses were also performed., Results: Among the 925 patients enrolled in the study, the SNOT-22 was completed after ESS by 641 patients (69.3%) at 1 year and 338 patients (36.5%) at 5 years. The mean preoperative SNOT-22 score of 48.5 (standard error [SE], 0.69) improved at all subsequent yearly time-points, including 5 years (mean, 25.8; SE, 1.08; p < 0.0001). SNOT-22 scores over time were impacted by nasal polyps (p < 0.001), environmental allergies (p = 0.010), diabetes (p = 0.032), and preoperative Lund-Mackay score (p < 0.001)., Conclusion: Endoscopic sinus surgery appears to be effective at improving the quality of life of patients with CRS for both the short and long term. The successful outcome of such surgery, however, is influenced by a variety of clinical factors, which should be taken into account by clinicians who are considering surgical treatment of CRS for select patients., (© 2021 ARS-AAOA, LLC.)

Background: Endoscopic dacryocystorhinostomy (EN-DCR) is an increasingly common procedure performed by otolaryngologists. While EN-DCR has a high rate of success at relieving blockage of the lacrimal system, little is known regarding associated postoperative infection (POI) rates and risk factors., Objective: The purpose of this study was to identify factors associated with the occurrence of postoperative orbital and rhinologic infection in a large cohort of patients undergoing EN-DCR., Methods: A retrospective review of 582 patients who underwent EN-DCR was performed. All patients received antibiotic prophylaxis as a single intraoperative intravenous administration and a ten-day postoperative oral course. Clinical and demographic information was reviewed, including the occurrence of acute orbital or rhinologic infection within 30 days of surgery. Multivariable analysis was performed to identify risk factors associated with POI., Results: Fifteen of 582 patients (2.6%) developed POI following EN-DCR. The most common POI was acute rhinosinusitis (10/15, 66.7%), followed by acute dacryocystitis (2/15, 13.3%), preseptal cellulitis (2/15,13.3%), and acute bacterial conjunctivitis (1/15, 6.7%). The majority of patients (464/582, 79.7%) underwent concurrent endoscopic sinus surgery (ESS). In most cases (302/464, 65.1%), ESS was performed to address comorbid rhinosinusitis, whereas 7.8% (36/464) of patients underwent surgery to enhance surgical access to the lacrimal sac. Patients who underwent concurrent ESS were less likely to develop POI (OR: 0.17, CI: 0.04-0.80, p < 0.05). Evidence of mucopurulence at surgery increased the likelihood of POI (OR: 6.24, CI: 1.51-25.84, p < 0.05)., Conclusion: Mucopurulence at the time of surgery significantly increased the risk of POI, whereas concurrent ESS, performed most commonly to address comorbid rhinosinusitis, significantly decreased the risk of POI. Awareness of risk factors for POI and appropriate surgical management of concurrent rhinosinusitis can lead to reduced infectious complications after EN-DCR.

Objective: Surgical education has undergone major changes in recent years, as hands-on learning opportunities have been replaced or supplemented with online tools. The goal of this project is to examine the educational impact of a surgical training website, SinusVideos.com, on otolaryngologists at various levels of training., Methods: Visitors to the website were asked to complete a survey after viewing a narrated video of a surgical procedure. Surveys were analyzed for demographics, needs assessment, and educational impact., Results: A total of 105 completed surveys were completed by 68 (64.8%) attendings/practicing physicians, 32 residents/fellows (30.5%), and 5 medical students (4.8%). Whereas 14.3% of viewers reported online videos as their primary source for surgical preparation, 70.5% considered them important secondary supplements. After viewing a video, 92.4% of respondents reported a gained confidence in performing the surgery, and 62.9% said the video altered how they would perform the surgery in the future. Viewers' ratings of their knowledge (on a 1-7 Likert scale) of a particular surgical procedure before vs after watching the observed procedure increased significantly for participants at all levels of training-medical students (2.8 before vs 5.4 after, P  < .01), residents/fellows (4.8 before vs 5.8 after, P  < .0001), and attendings/practicing physicians (5.6 before vs 6.4 after, P  < .0001)., Conclusion: High quality online surgical videos appear to be an effective learning tool for surgical trainees and practicing physicians alike. The educational benefit of such tools, as well as their widespread accessibility, makes them a powerful instrument for the training of surgeons worldwide., Level of Evidence: Level 5., Competing Interests: The authors declare have no conflicts of interest., (© 2021 The Authors. Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC. on behalf of The Triological Society.)

I., Executive Summary: BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document., Methods: ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary., Results: ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided., Conclusion: This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS., (© 2021 ARS-AAOA, LLC.)

Objective: Both endoscopic sinus surgery (ESS) and biologic therapies have shown effectiveness for medically-refractory chronic rhinosinusitis with nasal polyps (CRSwNP) without severe asthma. The objective was to evaluate cost-effectiveness of dupilumab versus ESS for patients with CRSwNP., Study Design: Cohort-style Markov decision-tree economic model with a 36-year time horizon., Methods: A cohort of 197 CRSwNP patients who underwent ESS were compared with a matched cohort of 293 CRSwNP patients from the SINUS-24 and SINUS-52 Phase 3 studies who underwent treatment with dupilumab 300 mg every 2 weeks. Utility scores were calculated from the SNOT-22 instrument in both cohorts. Decision-tree analysis and a 10-state Markov model utilized published event probabilities and primary data to calculate long-term costs and utility. The primary outcome measure was incremental cost per quality-adjusted life year (QALY), which is expressed as an Incremental Cost Effectiveness Ratio. One-way and probabilistic sensitivity analyses were performed., Results: The ESS strategy cost $50,436.99 and produced 9.80 QALYs. The dupilumab treatment strategy cost $536,420.22 and produced 8.95 QALYs. Because dupilumab treatment was more costly and less effective than the ESS strategy, it is dominated by ESS in the base case. One-way sensitivity analyses showed ESS to be cost-effective versus dupilumab regardless of the frequency of revision surgery and at any yearly cost of dupilumab above $855., Conclusions: The ESS treatment strategy is more cost effective than dupilumab for upfront treatment of CRSwNP. More studies are needed to isolate potential phenotypes or endotypes that will benefit most from dupilumab in a cost-effective manner., Level of Evidence: 2C Laryngoscope, 131:E26-E33, 2021., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

Removal of foreign bodies from the infratemporal fossa is surgically challenging and fraught with risks. This report describes our experience with a minimally invasive transoral technique, utilizing endoscopic and image guidance technology, for retrieval of infratemporal fossa foreign bodies in 6 patients. The technique was successfully applied in all cases with identification and retrieval of the foreign bodies, which included 4 hypodermic needles broken off during dental injections, a cottonoid surgical sponge lost during a facial fracture repair, and a maxillary molar displaced during attempted extraction. Complications were limited to transient postoperative lingual and inferior alveolar nerve sensory deficits in 1 patient., (© The Authors 2020.)

Objective: The primary aim of this study was to describe national variations in sinus balloon dilation (SBD), examine the relationship between endoscopic sinus surgery (ESS) and SBD prevalence patterns, and evaluate associations between reimbursement rates and regional variations in sinus surgery., Study Design: Retrospective observational study., Setting: Medicare Provider Utilization and Payment (PUP) Part B Data from January 1, 2016, to December 31, 2016., Subjects and Methods: Physicians in the PUP Part B Database Performing ESS or SBD in 2016. States were stratified into average- or high-volume utilizers based on the number of ESS procedures and SBD procedures per population and compared., Results: Eight states were classified as high-volume utilizers of SBD-Florida, Kansas, Louisiana, Mississippi, Nevada, New Mexico, South Dakota, and Texas. Only 3 of these states-Kansas, Mississippi, and Nevada-were classified as high-volume utilizers of ESS. Reimbursement rates were significantly higher for SBD as compared to ESS ($1538 [interquartile range (IQR), 1473-1664] vs $335 [IQR, 261-412] per procedure, P < .001). High-volume utilizer SBD states had a higher number of otolaryngologists (13.0 [IQR, 7-16] vs 6.0 [IQR, 2-3]) otolaryngologists per state ( P < .001) and a trend toward an increased rate of performing ESS procedures (19 [IQR, 19-41] vs 6.0 [IQR, 2-32], P = .034) procedures per million residents) than average-volume utilizer SBD states., Conclusions: The southern United States has a significantly higher rate of SBD procedures performed compared to the rest of the country, but these rates do not appear to be directly related to statewide variations in SBD reimbursement.

Objectives/hypothesis: Most patients who undergo endoscopic dacryocystorhinostomy (DCR) have a diagnosis of idiopathic nasolacrimal duct obstruction. The purpose of this study was to examine the impact of routine biopsy of the lacrimal sac performed at time of DCR on subsequent patient diagnosis and treatment., Study Design: Retrospective review., Methods: The histopathology of nasolacrimal specimens (n = 769), obtained from 654 consecutive patients undergoing endoscopic DCR by a single surgeon over a 30-year period, were reviewed. Specific focus included the identification of unanticipated pathologic findings as they related to pertinent patient demographics, clinical presentation, radiologic findings, and intraoperative observations., Results: The study population was 69.6% female, with an average age of 56.1 ± 18.2 years. Pathological findings of tissue from the nasolacrimal sac, which was routinely sampled in all cases, showed inflammation (n = 566 [73.6%]), normal histology (n = 147 [19.1%]), granulomas (n = 8 [1.0%]), and neoplastic process (n = 7 [0.9%]). Patient history, preoperative CT scan, and/or intraoperative findings alerted the surgeon to the possibility of an unusual diagnosis in 12 of the 15 patients. An unsuspected neoplastic or granulomatous cause of lacrimal obstruction was identified on intraoperative biopsy in three patients (0.46%)., Conclusions: Although neoplastic and granulomatous diseases are relatively rare causes of lacrimal obstruction necessitating DCR surgery, they may be identified by through patient evaluation in most cases and by routine intraoperative biopsy of the lacrimal sac in all cases., Level of Evidence: 4 Laryngoscope, 130:584-589, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Although endoscopic dacryocystorhinostomy (endo-DCR) is a common treatment of nasolacrimal duct obstruction, little is known about the determinants of surgical success and failure. The purpose of this study was to identify patient- and technique-specific factors that may influence surgical outcomes of primary and revision endo-DCR., Methods: A retrospective review was conducted of 596 patients who underwent endo-DCR over a 30-year period (1989-2018). Patients' demographics and surgical techniques were assessed., Results: Among the cohort of patients (n = 478) who underwent primary endo-DCR, 10% (n = 48) required revision surgery. Patients who failed primary DCR tended to be younger (p = 0.015) and were less likely to have chronic sinonasal inflammation on histopathology (p = 0.047) than the successful surgery group. After adjusting for patient demographics and comorbidities, the occurrence of a postoperative complication was significantly associated with primary DCR failure (odds ratio [OR], 2.2; p = 0.032). Among the cohort of patients (n = 118) who underwent revision endo-DCR, 8.5% (n = 10) required additional revision surgery. Patients who failed revision DCR tended to be younger (p = 0.022), more likely to have had intraoperative laser usage (p = 0.031), and more likely to have had an intraoperative complication (p = 0.013) than the successful revision surgery group. Endo-DCR failure was not associated with smoking status, middle turbinate resection, or intraoperative visualization of the internal common punctum (p > 0.05)., Conclusion: An understanding of factors associated with primary and revision endo-DCR failure can help to inform preoperative counseling, intraoperative surgical technique, and postoperative care in the treatment of patients with nasolacrimal duct obstruction., (© 2019 ARS-AAOA, LLC.)

Background: Orbital cavernous hemangiomas (OCH) are the most common adult orbital tumor and represent an ideal index lesion for endonasal orbital tumor surgery. In order to standardize outcomes reporting, an anatomic-based staging system was developed., Methods: An international, multidisciplinary panel of 23 experts in orbital tumor surgery was formed. A modified Delphi method was used to develop the cavernous hemangioma exclusively endonasal resection (CHEER) staging system with a total of 2 rounds being completed., Results: Tumors medial to a plane along the long axis of the optic nerve may be considered amenable for an exclusively endonasal resection. In select cases, tumors may extend inferolaterally if the tumor remains below a plane from the contralateral naris through the long axis of the optic nerve (ie, plane of resectability [POR]). This definition reached consensus with 91.3% of panelists in agreement. Five stages were designed based on increasing technical resection difficulty and potential for morbidity. Stages were based on the relationship of the tumor to the extraocular muscles, the inferomedial muscular trunk of the ophthalmic artery (IMT), and orbital foramina. Staging by anatomic location also reached consensus with 87.0% of panelists in agreement. Size was not included in the staging system due to the lack of agreement on the contribution of size to resection difficulty., Conclusion: Endoscopic orbital tumor surgery is a nascent field with a growing, yet heterogeneous, body of literature. The CHEER staging system is designed to facilitate international, high-quality, standardized studies establishing the safety, efficacy, and outcomes of endonasal resection of OCH., (© 2019 ARS-AAOA, LLC.)

Background: The objective of this study was to evaluate the impact of bilateral inferior turbinate reduction (BITR) on patient-reported quality of life (QOL) following endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS)., Methods: This was a prospective cohort study. Patients with CRS, who were recruited from 10 different otolaryngologic practices between 2011 and 2014, completed the 22-item Sino-Nasal Outcome Test (SNOT-22), Chronic Sinusitis Survey (CSS), and EuroQol 5 Dimension (EQ-5D) survey at baseline, and at 12, 24, 36, and 48 months after ESS. A total of 113 patients who underwent ESS with BITR were compared to 788 patients who underwent ESS without BITR., Results: Significant demographic and comorbid differences between BITR and non-BITR cohorts included age (41 vs 49 years, p < 0.0001), presence of asthma (19% vs 36%, p < 0.0001), prior sinus surgery (22% vs 53%, p < 0.0001), and concurrent septoplasty (80% vs 53%, p < 0.0001), respectively. On univariate analysis, patients who underwent ESS with or without BITR were found to have statistically significant improvement in disease-specific (SNOT-22 and CSS) and general (EQ-5D) QOL scores at years 1 through 4 (p < 0.05). On multivariate regression, however, the performance of BITR was not associated with any improvements in these outcome measures., Conclusion: Patients undergoing ESS achieve similar long-term improvement in both disease-specific and general QOL regardless of the performance of concurrent BITR., (© 2019 ARS-AAOA, LLC.)

Objective: To provide a comprehensive overview of the emerging role of periostin, an extracellular matrix protein, as a key component in the development, diagnosis, and treatment of patients with chronic rhinosinusitis., Data Sources: Medline database., Review Methods: A state of the art review was performed targeting English-language studies investigating the role of periostin in cardiopulmonary, neoplastic, and inflammatory diseases, with emphasis on recent advances in the study of periostin in chronic rhinosinusitis., Conclusions: Periostin has emerged as a novel biomarker and therapeutic target for numerous human pathologies, including cardiac, pulmonary, and neoplastic disease. The upregulation of periostin in chronic rhinosinusitis suggests the potential for similar roles among patients with sinonasal disease., Implications for Practice: Chronic rhinosinusitis is a widespread disease with major clinical and societal impact. A critical limitation in the current treatment of patients with chronic rhinosinusitis is the absence of clinically relevant biomarkers to guide diagnosis and treatment selection. A review of the literature supports a likely role of periostin as a biomarker of chronic rhinosinusitis, as well as a novel therapeutic target in the future treatment of patients with sinonasal disease.

The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 established value-based reimbursement as the new norm in health care. As part of this shift, public and private insurers have adopted bundled payments in an effort to improve quality and control cost. Arkansas recently implemented an otolaryngology-specific bundled payment, which reimburses episodes of care involving adenoidectomy and/or tonsillectomy. In this mandatory model, otolaryngologists have the potential for shared savings or losses based on spending relative to risk-adjusted historical benchmarks and performance on quality metrics. The initiative has resulted in reduced health care costs and rates of postoperative antibiotic prescription and secondary bleeding. However, this experiment also illustrates potential pitfalls with bundled payments, such as emphasis of quality metrics lacking clinical relevance and incentive for increased service volume. The Arkansas initiative offers important lessons for otolaryngologists as ongoing reform under MACRA brings episode-based care to the forefront of our field.

Objectives/hypothesis: To evaluate the impact of age on patient-reported quality of life (QOL) following endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS)., Study Design: Prospective cohort study., Methods: Six hundred thirty-six patients with CRS were recruited from 11 otolaryngologic practices and completed the sinonasal-specific, 22-item Sino-Nasal Outcome Test-22 (SNOT-22) and general health-related EuroQol 5-Dimension (EQ-5D) questionnaires at baseline and 12 and 24 months after ESS. Patients were grouped chronologically to determine whether age at time of ESS was associated with clinical outcomes., Results: Ages ranged from 18 to 80 years (mean ± standard deviation = 48.5 ± 14.4). Improvement was observed in postoperative SNOT-22 scores at 12 and 24 months for all decades of life. Similar improvements were observed for EQ-5D-based health utility value (HUV) scores in all decades of life, except for the eldest cohort (ages 70-80, N = 33), who did not exceed the minimal clinically important difference at either 12 or 24 months following ESS. In regression analysis, age was not associated with sinonasal-specific outcomes (change in SNOT-22 scores) at 12 (P = .507) or 24 months (P = .955). In general health-related outcomes, however, age was significantly associated with change in EQ-5D-based HUV scores from baseline to 12 months following ESS after adjusting for patient demographics, comorbidities, and surgical history (P = .049)., Conclusions: This study demonstrates that ESS for adult CRS sufferers offers improved QOL outcomes through the eighth decade of life. The impact of comorbidities on QOL needs to be carefully considered when assessing older patients for sinus surgery., Level of Evidence: 2b Laryngoscope, 128:2681-2687, 2018., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Balloon dilation (BD) is a controversial alternative to conventional sinus surgery. The role of industry on practice patterns remains unknown. The aim of this study was to determine whether industry payments from BD manufacturers influence practice patterns for otolaryngologists and evaluate how these payments change over time., Methods: Retrospective cohort study using Medicare Provider Utilization and Payment (PUP) Data and Center for Medicare and Medicaid Services Open Payments (OP) general payment datasets. A total of 294 otolaryngologists identified in the PUP dataset who performed BD procedures from January 1, 2013, to December 31, 2015, were cross-referenced in the OP dataset from January 1, 2014, to December 31, 2016, for BD manufacturer payments. Payments to surgeons performing BD stratified by amount, type, and number of procedures performed were primary outcome measures., Results: Of the 294 otolaryngologists reporting BD procedures, 223 (76%) received payments from a company that manufactures BD devices. Receipt of $2,500 in BD payments was associated with performance of one additional BD procedure, and consulting fees were most positively associated with performing additional BD procedures (P = 0.006). The providers receiving the most in BD payments were more likely to continue to receive the most in payments, regardless of number of BD procedures performed. Performing more BD procedures did not correlate with decrease in other sinus procedures., Conclusion: Payments to otolaryngologists from manufacturers of sinus BD devices are associated with the performance of an increased number of such procedures. Surgeons should consider the impact of interactions with industry when evaluating patients for BD procedures., Level of Evidence: 4. Laryngoscope, 128:1540-1545, 2018., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: The number of surgical procedures performed for frontal sinusitis and the associated costs have increased dramatically over the past decade. The purpose of this study was to evaluate the cost-effectiveness of endoscopic frontal sinusotomy (EFS) in patients with chronic rhinosinusitis with nasal polyposis (CRSwNP)., Study Design: Cohort-style Markov decision-tree economic model with a 36-year time horizon., Methods: Matched cohorts of CRSwNP patients who underwent endoscopic sinus surgery (ESS) with (n = 139) and without (n = 49) EFS were compared to each other and to patients (n = 139) from the Medical Expenditures Survey Panel database who underwent medical management for chronic rhinosinusitis. Multi-year health utility values were calculated from responses to the EuroQol 5-Dimension instrument. The primary outcome measure was the incremental cost-effectiveness ratio (ICER)., Results: Decision analysis showed that ESS without EFS proved more cost-effective than ESS with EFS or medical management. ESS without EFS compared to medical management yielded an ICER of $9,004/quality-adjusted life year (QALY). ESS with EFS compared to ESS without EFS yielded an ICER of $62,310/QALY. At a willingness-to-pay (WTP) threshold of $50,000/QALY, ESS without EFS was more cost-effective than ESS with EFS with 52.1% certainty. These results were robust to one-way analysis and probabilistic sensitivity analysis., Conclusions: ESS remains a cost-effective intervention compared to medical therapy alone for patients with CRSwNP. In this study, the addition of frontal sinusotomy during ESS for patients with CRSwNP was not found to be cost-effective at a WTP threshold of $50,000/QALY, but may be cost effective at a higher threshold of $100,000/QALY., Level of Evidence: 2c. Laryngoscope, 128:43-51, 2018., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective Periostin is an extracellular matrix protein that is elevated in the sinonasal tissues of patients with chronic rhinosinusitis (CRS). The purpose of this study was to determine whether serum periostin could serve as a molecular biomarker of nasal polyp burden in sinonasal disease. Study Design Prospective cohort study. Setting Academic medical center. Subjects and Methods Serum periostin levels were measured by ELISA on blood samples collected from patients undergoing sinus surgery for CRS (n = 71), further stratified by phenotype as defined by nasal polyps and asthma. Results were compared with assays performed on control subjects (n = 62). Results Mean serum periostin levels were markedly elevated in patients with CRS versus controls (66.1 ng/mL [95% CI, 51.6-80.6] vs 38.7 ng/mL [95% CI, 34.4-42.9], respectively, P = .004). In addition, mean periostin levels were significantly higher in CRS patients with nasal polyps as compared with those without polyps (94.8 ng/mL [95% CI, 67.3-122.4] vs 41.1 ng/mL [95% CI, 35.2-47.0], respectively, P < .001). Periostin levels did not correlate with sex ( P = .473), smoking history ( P = .748), aspirin-exacerbated respiratory disease status ( P = .136), oral steroid use within 1 month of surgery ( P = .281), use of topical steroid nasal spray ( P = .864), or number of prior sinus operations ( P = .973). Conclusion Serum periostin appears to be a novel molecular biomarker for the presence of nasal polyps and may serve as an indicator of CRS endotypes.

Background: The objective of this work was to evaluate the impact of asthma on the cost-effectiveness profile of endoscopic sinus surgery (ESS) compared to medical therapy for patients with chronic rhinosinusitis with nasal polyps (CRSwNP)., Methods: The study design consisted of a cohort-style Markov decision-tree cost utility analysis with a 35-year time horizon. Matched cohorts of CRSwNP patients with (n = 95) and without (n = 95) asthma who underwent ESS were compared with cohorts of patients from the national Medical Expenditures Survey Panel (MEPS) database who underwent medical management for chronic rhinosinusitis (CRS). Baseline, 1-year, and 2-year health utility values were calculated from responses to the EuroQol-5 Dimension (EQ-5D) instrument in both cohorts. The primary outcome measure was the incremental cost effectiveness ratio (ICER) for each cohort., Results: The reference cases for CRSwNP patients with and without asthma yielded ICERs for ESS vs medical therapy alone of $12,066 per quality-adjusted life year (QALY) and $7,369 per QALY, respectively. At a willingness-to-pay threshold of $50,000/QALY, the ICER scatter plots demonstrated 86% and 99% certainty that the ESS strategy was the most cost-effective option for CRSwNP patients with and without asthma, respectively. ESS was not significantly more cost effective for CRSwNP patients without asthma (p = 0.494)., Conclusion: ESS remains cost effective compared to medical therapy for patients both with and without asthma. While the comorbidity of asthma results in an inferior ICER result, it does not result in a statistically significant negative impact on the overall cost effectiveness of ESS., (© 2017 ARS-AAOA, LLC.)

Objective: Online resources may provide an ideal forum for expert presentation of surgical techniques. The purpose of this study was to investigate utilization patterns of a sinus surgery website, SinusVideos.com, to gain insight into the needs of viewers., Study Design: Retrospective analysis., Setting: Surgical teaching website., Subjects and Methods: The website's anonymized analytic database was queried from 2009 to 2014. Quantified data included user demographics, geographic location, viewing device, page visits, and time spent on the website., Results: A total of 428,691 website pages were viewed during the study period. Growth in viewership was observed each successive year since the site was launched. The mean time spent viewing webpages was 96.1 seconds for desktop computer users, 98.0 for tablet users, and 103.8 for mobile users. The percentage of mobile devices used to view the site increased significantly between 2009 and 2014 (2.1% vs 25.4%, respectively; P < .0001). The website's viewership expanded globally, with a significant increase in site views from outside North America over this same period (18.4% vs 51.7%, P < .0001)., Conclusion: The observed increase in global participation and mobile device usage may reflect new areas of growth for surgical education., Competing Interests: Competing interests: The website investigated in this article, SinusVideos.com, is developed and maintained by the senior author (R.M.) and contributed to by his fellows and colleagues. The site does not receive any outside funding, nor does it generate any income from its operation.

Objectives: To compare the causes of failure between external and endoscopic dacryocystorhinostomy (DCR) techniques for the treatment of lacrimal obstruction., Study Design: A retrospective cohort study., Methods: The study population consisted of 53 consecutive patients who underwent revision endoscopic DCR from 2002 to 2013 for lacrimal duct obstruction. Identified causes of previous DCR failure were compared between patients whose initial surgery was performed through an external versus an endoscopic approach., Results: Reasons for surgical failure after external (n = 21) versus endoscopic (n = 32) DCR included cicatricial closure of the internal lacrimal ostium (52.4 versus 53.1%; p = 0.96), inadequate removal of bone overlying the lacrimal sac (23.8 versus 9.4%; p = 0.15), sump syndrome (9.5 versus 9.4%; p = 0.99), and intranasal adhesions (65 versus 37.5%; p = 0.05). Adhesions that involved the middle turbinate were a particularly impactful cause of failure when the DCR was performed through an external versus the endoscopic approach (57.1 versus 28.1%; p = 0.04). Septoplasty was more likely to be needed at the time of revision surgery if the initial procedure was performed externally (71.1 versus 15.6%; p = 0.02). Surgical success rates for revision DCR were comparable between the groups (75.0% external versus 73.3% endoscopic; p = 0.90), with a mean follow-up of 12.7 months., Conclusion: DCR failure associated with intranasal adhesions was more likely to occur when the surgery was performed through an external rather than an endoscopic approach. Endoscopic instrumentation allowed for identification and correction of intranasal pathology at the time of DCR, including an enlarged middle turbinate or a deviated septum, which may improve surgical outcome.