Search

Objective: To assess long-term safety and effectiveness of a multipoint, impedance-controlled, RF ablation device for treatment of chronic rhinitis through 12-month follow-up., Methods: A prospective, multicenter study. Bilateral posterior nasal nerve (PNN) ablation was performed on all participants. Assessments at 6-, 9-, and 12-month visits included Visual Analog Scale Nasal Symptom Score (VAS NSS), reflective Total Nasal Symptom Score (rTNSS), mini-Rhinoconjunctivitis Quality of Life Questionnaire (mini RQLQ), and adverse events., Results: Thirty-six participants were enrolled and 35 completed the 12-month follow-up. All 5 VAS NSS items demonstrated statistically significant improvement ( p  < .0001) over baseline at all 3 time points. The total rTNSS improved from 7.9 ± 1.8 at baseline to 4.3 ± 2.1 at 6-months, 3.8 ± 2.4 at 9-months, and 4.0 ± 2.1 at 12-months (all p  < .0001). At 12-months, 91% (31/35) of participants had achieved the minimum clinically important difference (MCID) of a reduction from baseline of ≥1 point and 80% (28/35) of the participants met the responder criteria of ≥30% reduction from baseline. The total mean mini RQLQ was reduced from 3.0 ± 1.0 at baseline to 1.4 ± 0.8 at 6-months, 1.4 ± 1.0 at 9-months, and 1.3 ± 0.8 at 12-months (all p  < .0001). At 12-months, 86% (30/35) of participants achieved the MCID of a reduction from baseline of ≥0.4 points for the mini RQLQ. No related serious adverse events occurred during the study., Conclusions: Impedance-controlled RF ablation of the PNN is safe and resulted in durable, significant improvement in rhinitis symptoms and quality of life through 12-month follow-up., Trial Registration: The study is registered at www.clinicaltrials.gov with the unique identifier of NCT05324397., Level of Evidence: 4., Competing Interests: DDR, GD, MGD, DMY, and MS are medical advisor consultants and EMO is a medical writer consultant to Neurent Medical. KL has no conflicts to report., (© 2024 The Author(s). Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC on behalf of The Triological Society.)

Objective: Commonly used endoscopic grading scales, such as the nasal polyp scale, inadequately describe the degree of polyposis found postoperatively in the paranasal sinus cavities. The purpose of this study was to create a novel grading system that more accurately characterizes polyp recurrence in postoperative sinus cavities, the Postoperative Polyp Scale (POPS)., Methods: A modified Delphi method was utilized to establish the POPS using consensus opinion among 13 general otolaryngologists, rhinologists, and allergists. Postoperative endoscopy videos from 50 patients with chronic rhinosinusitis with nasal polyps were reviewed by 7 fellowship-trained rhinologists and scored according to the POPS. Videos were rated again 1 month later by the same reviewers, and scores were assessed for test-retest and inter-rater reliability., Results: Overall inter-rater reliability for the first and second reviews of the 52 videos was Kf = 0.49 (95% CI 0.42-0.57) and Kf = 0.50 (95% CI 0.42-0.57) for the POPS. Intra-rater reliability showed near-perfect test-retest reliability for the POPS with Kf = 0.80 (95% CI 0.76-0.84)., Conclusion: The POPS is an easy-to-use, reliable, and novel objective endoscopic grading scale that more accurately describes polyp recurrence in the postoperative state which will be useful in the future for measuring the efficacy of various medical and surgical interventions., Level of Evidence: 5 Laryngoscope, 133:2885-2890, 2023., (© 2023 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Safety and efficacy of the NEUROMARK® system for treating chronic rhinitis., Methods: A prospective, single-arm, multicenter study was performed on adults with chronic rhinitis who underwent radiofrequency ablation to the posterior nasal nerves. Primary endpoints were device-related serious adverse events (SAEs) at 1 month and change from baseline in visual analog scale nasal symptom scale (VAS NSS) for rhinorrhea and nasal congestion at 3 months. Total nasal symptom score (rTNSS) and mini Rhinoconjunctivitis Quality of Life Questionnaire (mini RQLQ) score were also evaluated., Results: Thirty-six participants were enrolled and completed follow-up at 1 and 3 months. Mean VAS NSS scores for rhinorrhea and nasal congestion demonstrated significant improvement at 3 months (both p  < .0001). The mean percent changes from baseline in VAS rhinorrhea and nasal congestion were 53% and 55%, respectively. Total scores and all individual rTNSS items significantly improved (all p  < .001) over the measured interval. Percent responder rate (≥30% reduction from baseline in total rTNSS) at 3 months was 78%. The total mean mini RQLQ scores, as well as all subdomains, improved significantly (all p  < .0001). At 3 months, 89% of participants reported a minimal clinically important difference of ≥0.4 point improvement in the mini RQLQ score. No SAEs occurred during the study., Conclusions: The NEUROMARK System is a novel radiofrequency ablation device that provides safe and effective treatment to the posterior nasal nerves for patients with chronic rhinitis. Study participants experienced statistically significant and clinically meaningful improvement in symptoms and quality of life assessments at 3 months post-procedure., Trial Registration: The study is registered at www.clinicaltrials.gov with the unique identifier of NCT05324397., Level of Evidence: 4., Competing Interests: Douglas D. Reh, Greg Davis, Marc G. Dubin, David M. Yen, and Michael Sillers are medical advisor consultants and Ellen M. O'Malley is a medical writer consultant to Neurent Medical. Kristopher Lay has no conflicts to report., (© 2023 The Authors. Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC on behalf of The Triological Society.)

The incidence of internal carotid artery (ICA) injury associated with endoscopic endonasal approaches to the pituitary is less than 1%. While parent vessel sacrifice has historically been the choice of treatment, vessel-preserving endovascular techniques have been reported. Although flow diversion offers endoluminal reconstruction, its major limitation is the delay in obtaining complete occlusion. We describe the use of a combined Pipeline embolization device (PED) with endoscopic endonasal repair using a fascia lata/muscle graft to treat an iatrogenic ICA pseudoaneurysm and report long-term radiographic follow-up. Further investigation into the utility of directed endoscopic endonasal repair of iatrogenic pseudoaneurysms initially treated with PED is necessary, especially given the need of post-PED anticoagulation and the rate of permanent neurological deficit after ICA sacrifice., Competing Interests: Conflict of Interest None declared., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Objective: Olfactory neuroblastoma (ONB) is a rare malignant neoplasm of the sinonasal cavity. Surgery has been and remains a mainstay of treatment for patients with this tumor. Open craniofacial resections have been the treatment of choice for many decades. More recently, experience has been growing with endoscopic approaches in the management of patients with ONB. The object of this study is to report the authors' experience over the past 11 years with ONB patients treated with purely endonasal endoscopic techniques., Methods: The authors performed a retrospective chart review of 20 consecutive patients with ONB who underwent a completely endonasal endoscopic approach for an oncological tumor resection at their institution between January 2006 and January 2017. Patient demographics, tumor stage, pathological grade, frozen section analysis, permanent margin assessment, perioperative complications, postoperative therapy, length of follow-up, and outcomes at last follow-up were collected and analyzed., Results: Eighteen patients presented with newly diagnosed disease, with a modified Kadish stage of A in 2 cases, B in 3, C in 11, and D in 2. Two patients presented with recurrent tumors. An average of 25.3 specimens per patient were examined by frozen section analysis. Although analysis of intraoperative frozen section margins was negative in all but 1 case, microscopic foci of tumor were found in 7 cases (35%) on permanent histopathological analysis. Perioperative complications occurred in 7 patients (35%) including 1 patient who developed a cerebrospinal fluid leak; there were no episodes of meningitis. All but 1 patient received postoperative radiotherapy, and 5 patients received postoperative chemotherapy. With a mean follow-up of over 5 years, 19 patients were alive and 1 patient died from an unrelated cause. There were 2 cases of tumor recurrence. The 5-year overall, disease-specific, and recurrence-free survival rates were 92.9%, 100%, and 92.9%, respectively., Conclusions: The current results provide additional evidence for the continued use of endoscopic procedures in the management of this malignancy.

Olfactory neuroblastoma (ONB) is a rare malignant neoplasm arising in the upper portion of the sinonasal cavity. To better understand the genetic bases for ONB, here we perform whole exome and whole genome sequencing as well as single nucleotide polymorphism array analyses in a series of ONB patient samples. Deletions involving the dystrophin (DMD) locus are found in 12 of 14 (86%) tumors. Interestingly, one of the remaining tumors has a deletion in LAMA2, bringing the number of ONBs with deletions of genes involved in the development of muscular dystrophies to 13 or 93%. This high prevalence implicates an unexpected functional role for genes causing hereditary muscular dystrophies in ONB.

Objective Epistaxis is a primary complaint in 90% to 96% of patients with hereditary hemorrhagic telangiectasia (HHT). Numerous surgical and medical treatments aim to decrease the frequency and severity of epistaxis in this patient population. Bevacizumab is a recombinant, humanized monoclonal antibody to vascular endothelial growth factor, an angiogenic factor elevated in HHT. It has been used in several forms to treat epistaxis in HHT but thus far, evidence-based recommendations are limited. Study Design Systematic review with evidence-based recommendations. Methods A systematic review of the literature following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed using Embase, MEDLINE, MEDLINE In-Process/Epub, and Cochrane databases. English language abstracts were reviewed for relevance. Results Eleven manuscripts met inclusion criteria and were analyzed. Submucosal injection, submucosal injection plus laser coagulation, intravenous (IV), and topical formulations of bevacizumab were evaluated for their therapeutic impact on epistaxis in patients with HHT. Three randomized controlled trials failed to show topical bevacizumab to be more effective in controlling epistaxis than saline or other moisturizers. Conclusions The use of submucosal and IV bevacizumab shows promise, but further study is necessary to determine the true efficacy in the treatment of epistaxis as only grade C level exists currently. Based on the available literature, the use of topical bevacizumab is not recommended (grade B).

Background: Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant hereditary disorder resulting in vascular dysplasia and formation of arteriovenous malformations. Recurrent epistaxis is a hallmark of the disease. An array of medical therapies are used in this patient population, but robust evidence-based recommendations regarding the medical treatment of epistaxis are lacking. This systematic review was performed to look at the current literature and make meaningful evidence-based recommendations., Methods: A search of the Ovid MEDLINE, Embase, and Cochrane databases was conducted by a research librarian. Abstracts in the English language and published in a peer-review journal were reviewed for relevance and inclusion. PRISMA guidelines were followed., Results: Eighteen studies met the inclusion criteria. In a few small studies, thalidomide was shown to consistently improve severity and frequency of epistaxis and improve hemoglobin concentrations while decreasing the need for transfusion. Tranexamic acid appeared to only impact the epistaxis severity score and not other clinical outcomes. Selective estrogen modulators (SERMs), propranolol, rose geranium oil, and N-acetylcysteine, have demonstrated promising efficacy in small trials., Conclusion: Appropriate medical therapies for epistaxis outcomes in HHT remain undefined, and there is no "gold standard." Many of the studies are small and the data reported are heterogeneous, and therefore the ability to make strong evidence-based recommendations is limited. However, many different medications appear to be promising options., (© 2018 ARS-AAOA, LLC.)

Objective To develop a clinical consensus statement on the use of sinus ostial dilation (SOD) of the paranasal sinuses. Methods An expert panel of otolaryngologists was assembled to represent general otolaryngology and relevant subspecialty societies. The target population is adults 18 years or older with chronic or recurrent rhinosinusitis (with or without nasal polyps, with or without prior sinus surgery) for whom SOD is being recommended, defined as endoscopic use of a balloon device to enlarge or open the outflow tracts of the maxillary, frontal, or sphenoid sinuses, as a standalone procedure or with endoscopic surgery. A modified Delphi method was used to distill expert opinion into clinical statements that met a standardized definition of consensus. Results After 3 iterative Delphi method surveys, 13 statements met the standardized definition of consensus while 45 statements did not. The clinical statements were grouped into 3 categories for presentation and discussion: (1) patient criteria, (2) perioperative considerations, and (3) outcomes. Strong consensus was obtained for not performing SOD in patients without sinonasal symptoms or positive findings on computed tomography (CT) in patients with symptoms only of headache or sleep apnea without criteria for sinusitis. In addition, strong consensus was met that CT scan of the sinuses was necessary before performing SOD and that surgeons need to understand and abide by regulations set forth by the US Food and Drug Administration if they choose to reuse/reprocess devices. Conclusion Expert panel consensus may provide helpful information for the otolaryngologist considering the use of SOD for the management of patients with a diagnosis of rhinosinusitis. This panel reached consensus on a number of statements that defined the use of SOD as inappropriate in the management of a variety of symptoms or diseases in the absence of underlying sinusitis. When patients meet the definition of chronic sinusitis as confirmed by CT scan, SOD of the sinuses can be indicated and/or effective in certain scenarios. Additional consensus statements regarding proper setting and safeguards for performing the procedure are described.

Background: Sellar pathology is increasingly addressed using the expanded endonasal approach (EEA). Although avascular graft reconstruction is an acceptable means to prevent cerebrospinal fluid leak, there are few data regarding sinonasal morbidity in these patients. In this study we compare rates of persistent postoperative crusting (PPC) and rhinosinusitis in patients undergoing sellar reconstruction with mucosal autografting and acellular dermal allografting (ADA)., Methods: Patients undergoing the EEA between 2008 and 2014 were categorized into 2 subgroups: mucosal reconstruction and ADA reconstruction. Univariate analyses were performed to compare differences in PPC and rhinosinusitis in these groups and to identify risk factors for sinonasal morbidity. Multivariate propensity matching analysis was performed to match ADA and mucosa reconstruction groups with respect to age, race, gender, smoking status, diabetes status, tumor type, tumor size, and revision vs primary surgery., Results: A total of 149 patients were identified. There were 105 patients reconstructed with autologous mucosa (70.5%) and 44 reconstructed with ADA (29.5%). Overall, PPC was seen in 20 patients (13.4%) and rhinosinusitis in 10 patients (6.7%). Propensity matching generated 39 patients reconstructed with ADA and 39 reconstructed with mucosa. There was a significant increase in PPC in patients reconstructed with ADA compared to those reconstructed with mucosa (8 of 39 [20.5%] vs 2 of 39 [5.1%], p = 0.04). There was no association between reconstruction with ADA and increased rhinosinusitis (3 of 39 [7.7%] vs 4 of 39 [10.3%], p = 0.64)., Conclusion: Sinonasal morbidity is not uncommon after sellar reconstruction. Patients undergoing sellar reconstruction with ADA may be at increased risk of postoperative crusting compared with those undergoing reconstruction with mucosa., (© 2017 ARS-AAOA, LLC.)

Background: Measuring quality outcomes is an important prerequisite to improve quality of care. Rhinosinusitis represents a high value target to improve quality of care because it has a high prevalence of disease, large economic burden, and large practice variation. In this study we review the current state of quality measurement for management of both acute (ARS) and chronic rhinosinusitis (CRS)., Methods: The major national quality metric repositories and clearinghouses were queried. Additional searches included the American Academy of Otolaryngology-Head and Neck Surgery database, PubMed, and Google to attempt to capture any additional quality metrics., Results: Seven quality metrics for ARS and 4 quality metrics for CRS were identified. ARS metrics focused on appropriateness of diagnosis (n = 1), antibiotic prescribing (n = 4), and radiologic imaging (n = 2). CRS quality metrics focused on appropriateness of diagnosis (n = 1), radiologic imaging (n = 1), and measurement of patient quality of life (n = 2). The Physician Quality Reporting System (PQRS) currently tracks 3 ARS quality metrics and 1 CRS quality metric. There are no outcome-based rhinosinusitis quality metrics and no metrics that assess domains of safety, patient-centeredness, and timeliness of care., Conclusions: The current status of quality measurement for rhinosinusitis has focused primarily on the quality domain of efficiency and process measures for ARS. More work is needed to develop, validate, and track outcome-based quality metrics along with CRS-specific metrics. Although there has been excellent work done to improve quality measurement for rhinosinusitis, there remain major gaps and challenges that need to be considered during the development of future metrics., (© 2017 ARS-AAOA, LLC.)

Background: Acute invasive fungal rhinosinusitis (AIFR) is a fulminant fungal infection seen in patients who are immunocompromised. Due to its rarity, there is little evidence regarding the appropriate antifungal treatment regimen, especially the degree of surgical intervention., Objective: To assess factors that impact short-term survival in AIFR as defined by survival to hospital discharge and to develop a staging system to predict survival and complete surgical resection., Methods: Fifty-four patients with histopathologically diagnosed AIFR who met inclusion criteria were identified between 1984 and 2014. Patient characteristics, disease extent, treatment modality, and short-term survival data were collected. Univariate analysis was performed to assess for factors associated with survival and increased likelihood of surgical resection., Results: Of 52 patients with adequate documentation, 36 (69.2%) survived their hospital stay. Complete surgical resection was the only factor associated with improved survival (survival, 95.5%; p < 0.01). A surgical staging system was proposed to guide probability of complete resection and overall prognosis, with stage I disease limited to the nasal cavity, stage II involving the paranasal sinuses, stage III involving the orbit, and stage IV with skull base or intracranial extension. The χ2 analyses showed a decreased likelihood of complete surgical resection with stage III or IV disease compared with stage I (resection, 90.9%) (stage III resection, 37.5% [p = 0.01]; stage IV resection, 16.7% [p = 0.002]). There was a decreased likelihood of survival associated with increasing disease stage compared with stage I (survival, 100%) (stage II survival, 60% [p = 0.009]; stage III survival, 62.5% [p = 0.02]; stage IV survival, 54.6%, [p = 0.006])., Conclusion: Although further studies are needed to define specific treatment protocols, analysis of these data indicated that endoscopic sinus surgery with the goal of complete surgical resection may provide the best survival outcomes in select patients when complete surgical resection can be performed. Our staging system represents the first attempt to predict surgical success and prognosis in patients with AIFR.

The cranial base is a complex 3-D region that contains critical neurovascular structures. Pathologies affecting this region represent some of the most challenging lesions to manage due to difficulty with access and risk of significant postoperative morbidity. With the development of expanded endonasal endoscopic approaches, skull base surgeons use the nose and paranasal sinuses as a corridor to access selected ventral skull base lesions. This review discusses high-resolution imaging in the evaluation of patients with skull base lesions considered for endonasal endoscopic surgery, summarizes various expanded endonasal endoscopic approaches, and provides examples of commonly used expanded endonasal endoscopic procedures., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives/hypothesis: Patients may perceive resident procedural participation as detrimental to their outcome. Our objective is to investigate whether otolaryngology-head and neck surgery (OHNS) housestaff participation is associated with surgical morbidity and mortality., Study Design: Case-control study., Methods: OHNS patients were analyzed from the American College of Surgeons National Surgical Quality Improvement Program 2006 to 2013 databases. We compared the incidence of 30-day postoperative morbidity, mortality, readmissions, and reoperations in patients operated on by resident surgeons with attending supervision (AR) with patients operated on by an attending surgeon alone (AO) using cross-tabulations and multivariable regression., Results: There were 27,018 cases with primary surgeon data available, with 9,511 AR cases and 17,507 AO cases. Overall, 3.62% of patients experienced at least one postoperative complication. The AR cohort had a higher complication rate of 5.73% than the AO cohort at 2.48% (P < .001). After controlling for all other variables, there was no significant difference in morbidity (odds ratio [OR] = 1.05 [0.89 to 1.24]), mortality (OR = 0.91 [0.49 to 1.70]), readmission (OR = 1.29 [0.92 to 1.81]), or reoperation (OR = 1.28 [0.91 to 1.80]) for AR compared to AO cases. There was no difference between postgraduate year levels for adjusted 30-day morbidity or mortality., Conclusions: There is an increased incidence of morbidity, mortality, readmission, and reoperation in OHNS surgical cases with resident participation, which appears related to increased comorbidity with AR patients. After controlling for other variables, resident participation was not associated with an increase in 30-day morbidity, mortality, readmission, or reoperation odds. These data suggest that OHNS resident participation in surgical cases is not associated with poorer short-term outcomes., Level of Evidence: 3b Laryngoscope, 126:2263-2269, 2016., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Although the nasoseptal flap has become the method of choice for reconstruction of intraoperative cerebrospinal fluid (CSF) leak in endoscopic minimally invasive surgery of the skull base, layered avascular graft techniques, including allografts and middle turbinate mucosal autografts, may provide comparable reconstructive success with decreased nasal morbidity., Objective: To describe a method of reconstruction of intraoperative CSF leak in endoscopic surgery of the sella turcica and analyze its postoperative success rate and associated comorbidities., Methods: A retrospective review of expanded endonasal sellar tumor resections from 2008-2014 was performed, and cases of layered intraoperative skull base reconstruction with avascular free grafts were identified. Demographic factors and comorbidities that predisposed to reconstruction failure (obstructive sleep apnea, obesity) were determined. Reconstruction-related nasal complications were also identified. Postoperative CSF leak rate was determined, and statistical analysis was performed to identify predictive factors for reconstructive failure., Results: Seventy-three cases were identified. Layered closure with avascular free grafts was performed. There were five cases of postoperative CSF leak (6.85%). The mean follow-up was 19 months (range, 1-76 months). Intraoperative high-flow CSF leak was a significant predictor of reconstruction failure on univariate (odds ratio 22 [95% confidence interval, 2.26-214]; p = 0.008) and multivariate analysis (odds ratio 33.6 [95% confidence interval, 2.30-492]; p = 0.010). There were no significant differences in postoperative leak rates among bony overlay graft types. There were five patients (7.9%) who experienced persistent crusting after surgery. There were no significant differences in crusting rates between allografts and mucosal grafts. There were no postoperative mucoceles., Conclusion: In cases of low-volume intraoperative CSF leak, layered skull base repair with avascular free grafts was an acceptable alternative to the nasoseptal flap, which may reduce prolonged sinonasal healing and donor-site morbidities.

Objectives/hypothesis: Hereditary hemorrhagic telangiectasia (HHT) is a disease of abnormal angiogenesis, causing epistaxis in over 96% of patients. The Epistaxis Severity Score (ESS) was developed as a standardized measurement of nasal symptoms among HHT patients. The minimal important difference (MID) of a disease index estimates the smallest change that a patient and clinician would identify as important. This study aims to establish the MID of the ESS in a diverse population of HHT patients., Study Design: Retrospective cross-sectional study in patients with a diagnosis of HHT using Curacao criteria or genetic testing., Methods: The ESS questionnaire and Medical Outcomes Study 36-Item Short Form (SF-36) were administered to participants recruited through the HHT Foundation Web site. Demographics and relevant medical histories were collected from all participants. An anchor-based method using a change of 5 in the Physical Component Summary (PCS) of the SF-36 and a distributional method were used to estimate the MID., Results: A total of 604 subjects were recruited between April and August 2008. All participants reported epistaxis. An increasing ESS in the study cohort showed a significant negative correlation to the PCS (r = -0.43, P < 0.001). The MID was determined to be 0.41 via the anchor-based approach and 1.01 via the distribution-based approach, giving a mean MID of 0.71., Conclusion: Using both the anchor-based and distribution-based approaches, the estimated MID for the ESS in HHT is 0.71. Further implications include key metrics to help guide treatment responses in clinical care and essential information to calculate power and sample size for future clinical trials., Level of Evidence: 4. Laryngoscope, 126:1029-1032, 2016., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Sinonasal malignancies represent a rare subset of tumors with a wide variety of histopathologic diagnoses and overall poor prognosis. These tumors tend to have an insidious onset with non-specific symptoms which often leads to delayed diagnosis and advanced local disease at presentation. The principal goal of surgery is to obtain a negative margin resection. Open craniofacial techniques are well established in the management of sinonasal malignancies and remain the treatment of choice for many advanced tumors. Over the past couple of decades, there has been tremendous application of endoscopic techniques to skull base pathologies including sinonasal malignancies. For selected cases, endonasal endoscopic techniques can be performed with curative intent and reduced surgical morbidity and mortality. Here we discuss principles of surgical management of sinonasal malignancies, review the techniques of endonasal endoscopic resection of sinonasal malignancies, and highlight the importance of pathology in the multi-disciplinary management of patients with these complex lesions.

Esthesioneuroblastoma is a rare malignant tumor of sinonasal origin. These tumors typically present with unilateral nasal obstruction and epistaxis, and diagnosis is confirmed on biopsy. Over the past 15 years, significant advances have been made in endoscopic technology and techniques that have made this tumor amenable to expanded endonasal resection. There is growing evidence supporting the feasibility of safe and effective resection of esthesioneuroblastoma via an expanded endonasal approach. This article outlines a technique for endoscopic resection of esthesioneuroblastoma and reviews the current literature on esthesioneuroblastoma with emphasis on outcomes after endoscopic resection of these malignant tumors., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Nasal polyps are semi-translucent mucosal outgrowths of the paranasal sinuses which typically arise in the setting of chronic rhinosinusitis (CRS). Nasal polyps are also associated with asthma, aspirin sensitivity, cystic fibrosis and allergic fungal rhinosinusitis (AFS). The majority of nasal polyps are bilateral and characterized by tissue edema and eosinophil infiltration. Patients with nasal polyps often present with complaints including nasal obstruction, congestion, rhinorrhea or altered sense of smell. The differential diagnosis ranges from benign masses such as schneiderian papilloma, antrochoanal polyp, angiofibroma and encephalocele to malignant neoplasms such as squamous cell carcinoma (SCC), esthesioneuroblastoma, nasal lymphoma and rhabdomyosarcoma. These lesions may have a similar appearance as nasal polyps and particular attention to an alternative diagnosis for nasal polyps should be entertained if the mass is unilateral or congenital in nature. Workup for patients with a unilateral mass should include radiographic imaging, possible biopsy and careful follow-up when appropriate. Here, we review the disease etiology of nasal polyps and describe the approach to the patient with nasal polyps with emphasis on differential diagnosis and workup., (© 2016 S. Karger AG, Basel.)

Background: Elevated intracranial pressure (ICP) is an inciting factor for cerebrospinal fluid (CSF) leaks and can be measured by CSF pressure (CSFP) monitoring. Current CSFP literature is limited to the assessments of opening pressure. This study reinvestigates a previously discussed monitoring approach that evaluates continuous CSFP parameters, physiologic measurements, and treatment outcomes in patients undergoing endoscopic repair of spontaneous CSF leaks., Methods: Retrospective review of patients undergoing endoscopic endonasal repair of spontaneous CSF leaks. All participants had a lumbar catheter placed for 24-hour continuous preoperative pressure monitoring, and 24 hours of continuous monitoring starting 48 hours after repair. In addition to patient characteristics, mean and peak CSFP, pulse waveform amplitudes (PWAs), and related parameters were calculated., Results: Twenty-five patients underwent monitoring between 2004 and 2013, with a mean follow-up of 526 days. The mean age was 49.2 years, the mean body mass index (BMI) 38.5, and 8 of 25 (32%) had obstructive sleep apnea. Although mean CSFP and PWA decreased after the repair, mean peak CSFP increased by 1.56 cmH2O (1.15 mmHg). Six patients (24%) had elevation in their CSFP >25 cmH2O (18.4 mmHg) for a minimum of 4% of the recording time. Based on their continuous pressure monitoring data, 9 patients (36%) underwent treatment for high ICP, either with acetazolamide or a ventricular shunt. There were no CSF leak recurrences., Conclusion: Continuous perioperative CSFP monitoring provides valuable insight into multiple physiologic parameters. Systematic continuous CSFP monitoring can identify individuals in need of ICP-lowering therapy, possibly improving the outcomes in CSF leak repair surgeries., (© 2014 ARS-AAOA, LLC.)

Background: Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disease mainly characterized by epistaxis in more than 96% of patients. Recently, a validated questionnaire known as the HHT Epistaxis Severity Score (ESS) was developed. However, little is known about the relationship between epistaxis and quality of life. We hypothesize that epistaxis severity is a major factor predicting health-related quality of life (HR-QoL) in HHT patients., Methods: This is a cross-sectional study. The ESS questionnaire and Medical Outcomes Study 36-item short form (SF-36) were administered to subjects through an Internet survey. All participants had a definitive diagnosis of HHT through Curaçao criteria or genetic testing. Demographic information, genetics, and extensive histories were also collected. Descriptive analyses were performed with calculations of means and standard deviations (SDs) for continuous variables and proportions for categorical variables. Linear regressions were then performed to assess the association between HR-QoL and ESS., Results: A total of 604 subjects participated between April and August 2008. All patients reported epistaxis, 285 (47.2%) had telangiectasias, and 545 (90.2%) had a family history of HHT; 167 (27.6%) patients had mild epistaxis (ESS <4), 285 (47.2%) reported moderate epistaxis (≥4 ESS <7), and 152 (25.2%) reported severe epistaxis (ESS ≥7). Patients with severe epistaxis had lower scores for both the Physical Component Summary (PCS) and the Mental Component Summary (MCS) of HR-QoL when compared to those with mild epistaxis (p < 0.001, p < 0.001)., Conclusion: The ESS is a major determinant of HR-QoL and should be considered as a measurement of treatment efficacy in HHT-related epistaxis., (© 2014 ARS-AAOA, LLC.)

Objectives/hypothesis: To examine the effects of a learner-centered educational curriculum for Johns Hopkins otolaryngology-head and neck surgery residents in improving their otolaryngology training examination (OTE) scores. We hypothesized that trainees who attend a learner-centered program demonstrate improved performance on OTEs., Study Design: Prospective longitudinal study., Methods: In September 2008, a resident-designed educational curriculum was implemented to better prepare residents for their OTE. These mandatory sessions, led by faculty members, were held for an hour every week, during in which residents were tested on their knowledge of high-yield topics. Residents were expected to be prepared on pathophysiology, diagnosis, and treatment of the selected diseases. In 2011, residents were given responsibility to lead these sessions. OTE scores from 2002 to 2012 were analyzed to see whether there was any improvement after the implementation of this curriculum., Results: Clustered linear regression analysis revealed significant improvement of OTE scores with subsequent interventions. During a 3-year period (2009-2011) after the first intervention, there was a significant increase (P = .01) of 0.69 in mean national and 0.78 in mean group stanine scoring. Similarly, after the second intervention in 2011, a further increment of 1.36 in mean national and 1.58 in mean group stanine scoring was seen (P = .001)., Conclusions: Residents OTE stanines improved significantly after the implementation of a learner-centered educational curriculum. This finding suggests that trainees are able to perform better when involved in planning and implementing the educational curriculum., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Hereditary hemorrhagic telangiectasia (HHT) is predominantly characterized by nasal telangiectases that cause severe epistaxis. Recently, the Epistaxis Severity Score (ESS) was developed and validated as a standardized measurement to evaluate epistaxis treatment efficacy. We propose a new endoscopic staging system to characterize nasal findings in HHT patients and correlate this to the ESS., Methods: This is a prospective cohort study. A total of 33 individuals with HHT confirmed by Curaçao criteria were recruited and evaluated by a single otolaryngologist between August 2010 and February 2013. Endoscopic parameters including patterns and sites of telangiectases and degree of nasal crusting were used to construct an endoscopy score for each subject. Multiple linear regression models were used to correlate this endoscopy score to the ESS., Results: A total of 33 subjects completed the study. The mean ± standard deviation (SD) age was 50.3 ± 13.2 years, and 20 (60.6%) were female. In the cohort, mean ± SD ESS was 4.05 ± 2.13 (range, 0.50 to 8.22). Most subjects (53.1%) had more than 4 nasal sites involved and (56.2%) had punctate telangiectases; 30.3% had mild crusting and 21.2% had moderate/severe crusting. These endoscopic findings were weighted by their correlation coefficients against epistaxis severity and normalized to create a new endoscopy score. After adjusting for confounding variables, the HHT Endoscopy Score (HES) was strongly associated with the ESS (r = 0.79, p < 0.001)., Conclusion: The HES correlates highly with patient-reported epistaxis severity and may provide a useful outcome measure in future studies., (© 2014 ARS-AAOA, LLC.)

Background: Chronic rhinosinusitis (CRS) is a prevalent and costly disease that adversely impacts quality of life. As with other chronic diseases, individual and environmental factors impact the disease process. Smoking and secondhand tobacco (SHS) exposures are important risk factors for CRS. However, little is known about the role that physicians play in educating sinusitis patients about this preventable risk. The objective of this study was to characterize physician participation in SHS exposure screening and education., Methods: The study was a community-based, case-control study of non-current smokers in Washington County, MD. One hundred cases with CRS were matched with 100 controls for age, sex, and former smoking status. We interviewed participants using a validated questionnaire that included questions on physician inquiry and recommendations pertaining to smoking and SHS exposure., Results: Over 80% of participants with CRS recalled their physician inquiring about their current smoking status, whereas only 27% recalled being asked by their physician about SHS exposure and only 23% reported that their physician recommended avoiding SHS. In contrast, more asthma participants recalled that their physicians inquired about SHS exposure (39.6%, although the difference was borderline significant p = 0.12) and recommended reducing SHS exposure (45.8%, p = 0.005)., Conclusion: Despite the increasing support for SHS exposure as a risk factor for CRS, relatively few physicians inquire about SHS and provide recommendations on SHS avoidance. Brief physician inquiry increases success of smoking cessation. Including SHS exposure in the medical history represents an opportunity for otolaryngologists to advise their patients about avoiding SHS and potentially alter disease outcomes., (© 2013 ARS-AAOA, LLC.)

Background: Maxillectomy defects require complex 3-dimensional reconstructions often best suited to microvascular free tissue transfer. Postoperative airway management during this procedure has little discussion in the literature and is often dictated by surgical dogma. The purpose of this article was to review our experience in order to evaluate the effect of airway management on perioperative outcomes in patients undergoing maxillectomy with free flap reconstruction., Methods: A retrospective chart review was performed on patients receiving maxillectomy with microvascular reconstruction at 2 institutions between 1999 and 2011. Patient's airways were managed with or without elective tracheotomy at the surgical team's discretion and different perioperative outcomes were measured. The primary outcome was incidence of airway complication including pneumonia and need for further airway intervention. Secondary outcome was measured as factors leading to perioperative performance of the tracheotomy., Results: Seventy-nine of 143 patients received elective tracheotomy perioperatively. The incidence of airway complication was equivalent between groups (10.1% vs 9.4%; p = .89). Patients with cardiopulmonary comorbidities were more likely to receive perioperative tracheotomy (74.1% vs 50.9%; p = .03) without a difference in airway complications. Other patient cofactors did not have an impact on perioperative tracheotomy or airway complication rate., Conclusions: Elective tracheotomy may safely be avoided in a subset of patients undergoing maxillectomy with microvascular reconstruction. Elective tracheotomy should be considered in patients with cardiopulmonary risk factors., (Copyright © 2012 Wiley Periodicals, Inc.)

The safety of endoscopic skull base surgery can be enhanced by accurate navigation in preoperative computed tomography (CT) or, more recently, intraoperative cone-beam CT (CBCT). The ability to register real-time endoscopic video with CBCT offers an additional advantage by rendering information directly within the visual scene to account for intraoperative anatomical change. However, tracker localization error (  ∼ 1-2 mm ) limits the accuracy with which video and tomographic images can be registered. This paper reports the first implementation of image-based video-CBCT registration, conducts a detailed quantitation of the dependence of registration accuracy on system parameters, and demonstrates improvement in registration accuracy achieved by the image-based approach. Performance was evaluated as a function of parameters intrinsic to the image-based approach, including system geometry, CBCT image quality, and computational runtime. Overall system performance was evaluated in a cadaver study simulating transsphenoidal skull base tumor excision. Results demonstrated significant improvement in registration accuracy with a mean reprojection distance error of 1.28 mm for the image-based approach versus 1.82 mm for the conventional tracker-based method. Image-based registration was highly robust against CBCT image quality factors of noise and resolution, permitting integration with low-dose intraoperative CBCT.

Nasal crusting, rhinitis, and sinusitis are presentations of common conditions; however, these can also be the presenting symptoms of an underlying systemic disorder such as an infection, malignancy, or granulomatous disease. Granulomatous diseases with head and neck manifestations include Wegener's granulomatosis, Churg-Strauss syndrome, and sarcoidosis. These diseases are managed through a multidisciplinary approach that often includes otolaryngologists. This article presents a brief review of granulomatous diseases and their rhinologic manifestations and includes relevant diagnostic tests and systemic and local treatment options.

Benign sinonasal neoplasms are a heterogeneous group of tumors that present with similar symptoms including nasal obstruction, anosmia, rhinorrhea, and epistaxis. The proper workup and accurate diagnosis is essential for these tumors so that the appropriate treatment plan can be established. In this article of benign sinonasal neoplasms, we discuss their typical clinical presentation, histological and radiographic findings, and treatment options.

Objectives/hypothesis: Topical Sesame/Rose geranium oil compound is an effective therapy for hereditary hemorrhagic telangiectasia (HHT) associated epistaxis., Study Design: Cohort Study., Methods: Twenty patients with HHT confirmed by the Curaçao criteria were treated with a sesame/rose geranium oil topical compound between January 2010 and June 2011. A treatment evaluation survey was conducted at least 3 months after treatment initiation. Changes in epistaxis severity scores (ESS), patient satisfaction, and any adverse effects were assessed., Results: A total of 20 patients completed the study. The average (SD) age was 54.4 (14.6), and 14 (70%) were female. The median time on rose geranium oil was 183 days (IQR: 114-311). At the conclusion of the study, 18 (90%) were still using rose geranium oil. The majority (75%) of patients subjectively felt improvement with the treatment. The improvement was felt to be gradual in 25% and immediate in 50% of patients. Mean (SD) overall satisfaction using a 10-point Likert scale was 7.8 (3.1), with 50% of the patients reporting a satisfaction rating of 10. Mean (SD) epistaxis severity score (ESS) prior to treatment was 5.3 (1.7). After treatment with sesame/rose geranium oil, mean (SD) ESS was found to be 3.5 (1.8). Treatment with sesame/rose geranium oil was associated with a statistically significant improvement in ESS by 1.81 (P <0.0001). There were no adverse side-effects from the treatment., Conclusion: A sesame/rose geranium oil compound can significantly reduce the epistaxis severity scores of patients with hereditary hemorrhagic telangiectasia-related epistaxis., (Copyright © 2013 The American Laryngological, Rhinological, and Otological Society, Inc.)

Esthesioneuroblastoma, or olfactory neuroblastoma, is an uncommon malignant tumor arising in the upper nasal cavity. Surgical approaches to this and other sinonasal malignancies involving the anterior skull base have traditionally involved craniofacial resections. Over the past 10 years to 15 years, there have been advances in endoscopic approaches to skull base pathologies, including malignant tumors. In this study, we review our experience with purely endoscopic approaches to esthesioneuroblastomas. Between January 2005 and February 2012, 11 patients (seven men and four women, average age 53.3 years) with esthesioneuroblastoma were treated endoscopically. Nine patients presented with newly diagnosed disease and two were treated for tumor recurrence. The modified Kadish staging was: A, two patients (18.2%); B, two patients (18.2%); C, five patients (45.5%); and D, two patients (18.2%). All patients had a complete resection with negative intraoperative margins. Three patients had 2-deoxy-2-((18)F)fluoro-d-glucose avid neck nodes on their preoperative positron emission tomography-CT scan. These patients underwent neck dissections; two had positive neck nodes. Perioperative complications included an intraoperative hypertensive urgency and pneumocephalus in two different patients. Mean follow-up was over 28 months and all patients were free of disease. This series adds to the growing experience of purely endoscopic surgical approaches in the treatment of skull base tumors including esthesioneuroblastoma. Longer follow-up on larger numbers of patients is required to clarify the utility of purely endoscopic approaches in the management of this malignant tumor., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

The co-existence of pituitary adenomas (PA) and carotid artery aneurysms has been described and may be particularly frequent in acromegaly. The co-occurrence of an intracranial aneurysm in the setting of a PA presents significant risk to the patient, particularly when the aneurysm is within or near the operative field. We describe a 48-year-old, right-handed female patient with a large skull base lesion who had a left cavernous carotid artery aneurysm detected on her preoperative imaging studies. This patient was managed using a staged approach. She first underwent endovascular stent-assisted coiling of the aneurysm followed, six months later, by resection of the tumor via an expanded endonasal endoscopic approach. Histopathological analysis revealed a pituitary macroadenoma with neuronal metaplasia. Angiographic embolization followed by an expanded endonasal endoscopic approach is a safe and effective treatment for such lesions. Vascular imaging studies and a low index for suspicion are required for preoperative identification of such complex situations., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objectives/hypothesis: To determine whether incorporation of intraoperative imaging via a new cone-beam computed tomography (CBCT) image-guidance system improves accuracy and facilitates resection in sinus and skull-base surgery through quantification of surgical performance., Study Design: Landmark identification and skull base ablation tasks were performed with a CBCT intraoperative image-guidance system in the experimental group and with image-guided surgery (IGS) alone based on preoperative computed tomography (CT) in the control group., Methods: Six cadaveric heads underwent preoperative CT imaging and surgical planning identifying surgical targets. Three types of surgical tasks were planned: landmark point identification, line contour identification, and volume drill-out. Key anatomic structures (carotid artery and optic nerve) were chosen for landmark identification and line contour tasks. Complete ethmoidectomy, vidian corridor drill-out, and clival resection were performed for volume ablation tasks. The CBCT guidance system was used in the experimental group and performance was assessed by metrics of target registration error, sensitivity, and specificity of excision., Results: Significant improvements were seen for point identification and line tracing tasks. Additional resection was performed in 67% of tasks in the CBCT group, and qualitative feedback indicated unequivocal improvement in confidence for all tasks. In review of tasks in the control group, additional resection would have been performed in 35% of tasks if an intraoperative image was available., Conclusions: An experimental prototype C-arm CBCT guidance system was shown to improve surgical precision in the identification of skull base targets and increase accuracy in the ablation of surgical target volumes in comparison to using IGS alone., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

Background: Environmental factors such as inhaled pollutants like cigarette smoke may play a significant role in diseases of the upper airway including chronic rhinosinusitis (CRS). The objectives of this review are to summarize prior studies that describe the correlation between active smoking and secondhand smoke (SHS) on CRS. We also review the pathophysiologic effects of cigarette smoke on sinonasal mucosa and discuss its impact on surgical outcomes of endoscopic sinus surgery (ESS)., Methods: A literature search was conducted of the PubMed database using the terms "sinusitis" or "rhinosinusitis" and "smoking." Additional search terms of "nasal epithelial" and "smoke" were used to find articles that discussed pathophysiologic effects of tobacco smoke, whereas "secondhand smoke" was added to identify articles analyzing the correlation of SHS and CRS. Finally "endoscopic sinus surgery" and "outcomes" were linked to "smoking" to find articles that analyzed the impact of smoking on surgical results., Results: We identified 204 articles in the initial search. An additional 72 articles were reviewed for their relevance to the pathophysiologic effects of tobacco smoke while 31 articles were analyzed to determine the correlation of SHS and CRS. Twenty-nine articles were reviewed to analyze the impact of smoking on surgical results., Conclusion: There is clear evidence in the literature that cigarette smoke, either through active smoking or passive exposure to SHS, contributes to CRS. Recent prospective studies suggest that active smoking is not a contraindication to ESS, whereas the impact of smoking volume and long-term smoking after ESS has not been sufficiently evaluated., (Copyright © 2012 American Rhinologic Society-American Academy of Otolaryngic Allergy, LLC.)

Purpose: A deformable registration method capable of accounting for missing tissue (e.g., excision) is reported for application in cone-beam CT (CBCT)-guided surgical procedures. Excisions are identified by a segmentation step performed simultaneous to the registration process. Tissue excision is explicitly modeled by increasing the dimensionality of the deformation field to allow motion beyond the dimensionality of the image. The accuracy of the model is tested in phantom, simulations, and cadaver models., Methods: A variant of the Demons deformable registration algorithm is modified to include excision segmentation and modeling. Segmentation is performed iteratively during the registration process, with initial implementation using a threshold-based approach to identify voxels corresponding to "tissue" in the moving image and "air" in the fixed image. With each iteration of the Demons process, every voxel is assigned a probability of excision. Excisions are modeled explicitly during registration by increasing the dimensionality of the deformation field so that both deformations and excisions can be accounted for by in- and out-of-volume deformations, respectively. The out-of-volume (i.e., fourth) component of the deformation field at each voxel carries a magnitude proportional to the excision probability computed in the excision segmentation step. The registration accuracy of the proposed "extra-dimensional" Demons (XDD) and conventional Demons methods was tested in the presence of missing tissue in phantom models, simulations investigating the effect of excision size on registration accuracy, and cadaver studies emulating realistic deformations and tissue excisions imparted in CBCT-guided endoscopic skull base surgery., Results: Phantom experiments showed the normalized mutual information (NMI) in regions local to the excision to improve from 1.10 for the conventional Demons approach to 1.16 for XDD, and qualitative examination of the resulting images revealed major differences: the conventional Demons approach imparted unrealistic distortions in areas around tissue excision, whereas XDD provided accurate "ejection" of voxels within the excision site and maintained the registration accuracy throughout the rest of the image. Registration accuracy in areas far from the excision site (e.g., > ∼5 mm) was identical for the two approaches. Quantitation of the effect was consistent in analysis of NMI, normalized cross-correlation (NCC), target registration error (TRE), and accuracy of voxels ejected from the volume (true-positive and false-positive analysis). The registration accuracy for conventional Demons was found to degrade steeply as a function of excision size, whereas XDD was robust in this regard. Cadaver studies involving realistic excision of the clivus, vidian canal, and ethmoid sinuses demonstrated similar results, with unrealistic distortion of anatomy imparted by conventional Demons and accurate ejection and deformation for XDD., Conclusions: Adaptation of the Demons deformable registration process to include segmentation (i.e., identification of excised tissue) and an extra dimension in the deformation field provided a means to accurately accommodate missing tissue between image acquisitions. The extra-dimensional approach yielded accurate "ejection" of voxels local to the excision site while preserving the registration accuracy (typically subvoxel) of the conventional Demons approach throughout the rest of the image. The ability to accommodate missing tissue volumes is important to application of CBCT for surgical guidance (e.g., skull base drillout) and may have application in other areas of CBCT guidance.

Purpose: As cone-beam CT (CBCT) systems dedicated to various imaging specialties proliferate, technical assessment grounded in imaging physics is important to ensuring that image quality and radiation dose are quantified, understood, and justified. This paper involves technical assessment of a new CBCT scanner (CS 9300, Carestream Health, Rochester, NY) dedicated to imaging of the ear and sinuses for applications in otolaryngology-head and neck surgery (OHNS). The results guided evaluation of technique protocols to minimize radiation dose in a manner sufficient for OHNS imaging tasks., Methods: The technical assessment focused on the imaging performance and radiation dose for each of seven technique protocols recommended by the manufacturer: three sinus protocols and four ear (temporal bone) protocols. Absolute dose was measured using techniques adapted from AAPM Task Group Report No. 111, involving three stacked 16 cm diameter acrylic cylinders (CTDI phantoms) and a 0.6 cm(3) Farmer ionization chamber to measure central and peripheral dose. The central dose (D(o)) was also measured as a function of longitudinal position (z) within and beyond the primary radiation field to assess, for example, out-of-field dose to the neck. Signal-difference-to-noise ratio (SDNR) and Hounsfield unit (HU) accuracy were assessed in a commercially available quality assurance phantom (CATPHAN module CTP404, The Phantom Laboratory, Greenwich, NY) and a custom phantom with soft-tissue-simulating plastic inserts (Gammex RMI, Madison, WI). Spatial resolution was assessed both qualitatively (a line-pair pattern, CATPHAN module CTP528) and quantitatively (modulation transfer function, MTF, measured with a wire phantom). Imaging performance pertinent to various OHNS imaging tasks was qualitatively assessed using an anthropomorphic phantom as evaluated by two experienced OHNS specialists., Results: The technical assessment motivated a variety of modifications to the manufacturer-specified protocols to provide reduced radiation dose without compromising pertinent task-based imaging performance. The revised protocols yielded D(o) ranging 2.9-5.7 mGy, representing a ∼30% reduction in dose from the original technique chart. Out-of-field dose was ∼10% of D(o) at a distance of ∼8 cm from the field edge. Soft-tissue contrast resolution was fairly limited (water-brain SDNR ∼0.4-0.7) while high-contrast performance was reasonably good (SDNR ∼2-4 for a polystyrene insert in the CATPHAN). The scanner does not demonstrate (or claim to provide) accurate HU and exhibits a systematic error in CT number that could potentially be addressed by further calibration. The spatial resolution is ∼10-16 lp∕cm as assessed in a line-pair phantom, with MTF exceeding 10% out to ∼20 lp∕cm. Qualitative assessment by expert readers suggested limited soft-tissue visibility but excellent high-contrast (bone) visualization with isotropic spatial resolution suitable to a broad spectrum of pertinent sinus and temporal bone imaging tasks., Conclusions: The CBCT scanner provided spatial and contrast resolution suitable to visualization of high-contrast morphology in sinus, maxillofacial, and otologic imaging applications. Rigorous technical assessment guided revision of technique protocols to reduce radiation dose while maintaining image quality sufficient for pertinent imaging tasks. The scanner appears well suited to high-contrast sinus and temporal bone imaging at doses comparable to or less than that reported for conventional diagnostic CT of the head.

Background: The present study uses population-based data from the Surveillance, Epidemiology, and End Results (SEER) database to evaluate the behavior of sinonasal tumors., Methods: Data for all sinonasal malignancies reported between 1973 and 2006 (n = 6739) were extracted from the database. Time-dependent trends in incidence and survival were analyzed by linear regression., Results: The overall incidence of sinonasal cancer was 0.556 cases per 100,000 population per year with a male:female ratio of 1.8:1. The most common histologies were squamous cell carcinoma (51.6%) and adenocarcinoma (12.6%), whereas the most common primary sites were the nasal cavity (43.9%) and maxillary sinus (35.9%). The incidence of sinonasal cancer remained relatively stable during the study period. No significant changes in overall relative survival were noted. The best relative survival was noted in patients treated with surgery or a combination of surgery and radiotherapy., Conclusions: The prognosis of patients with sinonasal cancer is generally poor, and has not changed substantially over the last 3 decades., (Copyright © 2011 Wiley Periodicals, Inc.)

Purpose of Review: To review the current knowledge of the pathophysiology, epidemiology, and management of environmental pollutants and allergic rhinitis., Recent Findings: Both active cigarette smoking and passive exposure to cigarette smoke are associated with chronic rhinitis and sinusitis. Matrix metalloproteinase 9, which is thought to contribute to the pathophysiology of allergy, is elevated in children with passive cigarette smoke exposure compared with controls. Ground-level ozone and particulate matter exposure is associated with an allergic-type response and may increase sensitization to other allergens. Certain occupational exposures can cause nasal irritation and local cytotoxic effects. Evidence suggests that rhinitis symptomatology may often precede the development of occupational asthma., Summary: Environmental factors have been noted to induce sinonasal mucosal irritation and often contribute to the multifactorial cause of chronic rhinitis and allergic rhinitis. Cigarette smoke is a common irritant that impacts the innate immune function of the sinonasal epithelial cells, and creates local irritation and cytotoxic effects. Both active smoking and exposure to second-hand smoke increase the risk of chronic rhinitis. Many other environmental pollutants are associated with chronic rhinitis, including ozone, particulate matter, and occupational irritants. The management of chronic rhinitis associated with environmental exposures is similar to the management of other types of chronic rhinitis. Although often not feasible, avoidance is probably the most effective course.

Augmentation of endoscopic video with preoperative or intraoperative image data [e.g., planning data and/or anatomical segmentations defined in computed tomography (CT) and magnetic resonance (MR)], can improve navigation, spatial orientation, confidence, and tissue resection in skull base surgery, especially with respect to critical neurovascular structures that may be difficult to visualize in the video scene. This paper presents the engineering and evaluation of a video augmentation system for endoscopic skull base surgery translated to use in a clinical study. Extension of previous research yielded a practical system with a modular design that can be applied to other endoscopic surgeries, including orthopedic, abdominal, and thoracic procedures. A clinical pilot study is underway to assess feasibility and benefit to surgical performance by overlaying CT or MR planning data in real-time, high-definition endoscopic video. Preoperative planning included segmentation of the carotid arteries, optic nerves, and surgical target volume (e.g., tumor). An automated camera calibration process was developed that demonstrates mean re-projection accuracy (0.7±0.3) pixels and mean target registration error of (2.3±1.5)mm. An IRB-approved clinical study involving fifteen patients undergoing skull base tumor surgery is underway in which each surgery includes the experimental video-CT system deployed in parallel to the standard-of-care (un-augmented) video display. Questionnaires distributed to one neurosurgeon and two otolaryngologists are used to assess primary outcome measures regarding the benefit to surgical confidence in localizing critical structures and targets by means of video overlay during surgical approach, resection, and reconstruction.

Historically concurrent FESS/rhinoplasty was avoided due to concerns of increased risk of complication. Recent studies have shown that FESS/rhinoplasty can be performed simultaneously with good outcomes and no significant increase in complications. A thorough and effective approach to the patient with sinonasal obstruction requires attention to aesthetic, functional, and inflammatory issues. Medical treatment is an important adjuvant to surgery in order to optimize outcomes by improving patient symptoms long-term. Surgery for these patients should be performed in a careful, stepwise approach to address the nasal septum, inferior turbinates, paranasal sinuses, and external nasal structures., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Benign smooth muscle tumors rarely occur in the head and neck and, to the best of our knowledge, have not been reported in the pterygopalatine fossa. In this report, we describe a 15-year-old adolescent who presented with facial pain and was found to have a large skull base tumor centered in the pterygopalatine fossa. The patient underwent an expanded endonasal endoscopic approach for complete resection of this lesion with resolution of his symptoms. Pathology revealed a well-differentiated smooth muscle neoplasm consistent with a leiomyoma. This case adds to the growing body of literature supporting a role for endoscopic procedures in the treatment of skull base pathologies in pediatric patients.

Purpose: A system architecture has been developed for integration of intraoperative 3D imaging [viz., mobile C-arm cone-beam CT (CBCT)] with surgical navigation (e.g., trackers, endoscopy, and preoperative image and planning data). The goal of this paper is to describe the architecture and its handling of a broad variety of data sources in modular tool development for streamlined use of CBCT guidance in application-specific surgical scenarios., Methods: The architecture builds on two proven open-source software packages, namely the cisst package (Johns Hopkins University, Baltimore, MD) and 3D Slicer (Brigham and Women's Hospital, Boston, MA), and combines data sources common to image-guided procedures with intraoperative 3D imaging. Integration at the software component level is achieved through language bindings to a scripting language (Python) and an object-oriented approach to abstract and simplify the use of devices with varying characteristics. The platform aims to minimize offline data processing and to expose quantitative tools that analyze and communicate factors of geometric precision online. Modular tools are defined to accomplish specific surgical tasks, demonstrated in three clinical scenarios (temporal bone, skull base, and spine surgery) that involve a progressively increased level of complexity in toolset requirements., Results: The resulting architecture (referred to as "TREK") hosts a collection of modules developed according to application-specific surgical tasks, emphasizing streamlined integration with intraoperative CBCT. These include multi-modality image display; 3D-3D rigid and deformable registration to bring preoperative image and planning data to the most up-to-date CBCT; 3D-2D registration of planning and image data to real-time fluoroscopy; infrared, electromagnetic, and video-based trackers used individually or in hybrid arrangements; augmented overlay of image and planning data in endoscopic or in-room video; and real-time "virtual fluoroscopy" computed from GPU-accelerated digitally reconstructed radiographs (DRRs). Application in three preclinical scenarios (temporal bone, skull base, and spine surgery) demonstrates the utility of the modular, task-specific approach in progressively complex tasks., Conclusions: The design and development of a system architecture for image-guided surgery has been reported, demonstrating enhanced utilization of intraoperative CBCT in surgical applications with vastly different requirements. The system integrates C-arm CBCT with a broad variety of data sources in a modular fashion that streamlines the interface to application-specific tools, accommodates distinct workflow scenarios, and accelerates testing and translation of novel toolsets to clinical use. The modular architecture was shown to adapt to and satisfy the requirements of distinct surgical scenarios from a common code-base, leveraging software components arising from over a decade of effort within the imaging and computer-assisted interventions community.

Background: Approximately 20% of the U.S. population suffers from allergic rhinitis (AR), and chronic rhinosinusitis (CRS) is estimated to affect 12.5% of the population. Frequently, many patients suffer from both disorders. In this study, we evaluated the relationship between AR and chronic rhinosinusitis as far as impact on nasal symptoms in a community-based case-control study of adult nonsmokers., Methods: In Washington County, MD, 200 subjects were recruited and interviewed from the same community. Subjects were divided into 4 study groups: AR without CRS, CRS without AR, AR with CRS, and a control group without AR or CRS. A validated questionnaire was used to assess upper respiratory symptoms, and disease-specific quality of life., Results: Upper respiratory symptoms were significantly more severe for the affected subjects when compared to controls. Symptom severity was greatest for the CRS groups with or without AR, followed by AR without CRS, and controls least symptomatic. Subjects with AR plus CRS were most likely to have had previous nasal surgery, and use nasal decongestants when compared to the other groups., Conclusion: While both AR and CRS are common in the United States, it appears that patients who suffer from both disorders have more severe symptoms and are more likely to have undergone nasal surgery than if they have only 1 of these disease states., (Copyright © 2011 American Rhinologic Society-American Academy of Otolaryngic Allergy, LLC.)

Esthesioneuroblastoma is an uncommon malignant tumor originating in the upper nasal cavity. The surgical treatment for this tumor has traditionally been via an open craniofacial resection. Over the past decade, there has been tremendous development in endoscopic techniques. In this report, we performed a retrospective analysis of patients with esthesioneuroblastomas treated with a purely endonasal endoscopic approach and resection at the Johns Hopkins Hospital between January 2005 and April 2010. A total of eight patients with esthesioneuroblastoma, five men and three women, were identified. Six patients were treated for primary disease, and two were treated for tumor recurrence. The modified Kadish staging was A in one patient (12.5%), B in two patients (25%), C in four patients (50%), and D in one patient (12.5%). All patients had a complete resection with negative intraoperative margins. One patient had intraoperative hypertension; there were no perioperative complications. With a mean follow-up of over 27 months, all patients are without evidence of disease. In addition, we reviewed the literature and identified several overlapping case series of patients with esthesioneuroblastoma treated via a purely endoscopic technique. Our series adds to the growing experience of expanded endonasal endoscopic surgery in the treatment of skull base tumors including esthesioneuroblastoma. Longer follow-up on a larger number of patients is required to further demonstrate the utility of endoscopic approaches in the management of this malignancy.

Objectives/hypothesis: Unilateral frontal sinus obstruction presents a surgical challenge when outflow tract osteoneogenesis or dense scarring is present. Frontal sinus obliteration is often employed as a last resort, but this procedure has potential long-term complications. In some cases, endoscopic modified Lothrop or unilateral drillout procedures may be effective options; however, restenosis rates are often high. Here we report our experience using frontal intersinus septum takedown (FISST) to address unilateral obstruction while preserving the opposite frontal outflow tract., Study Design: A retrospective review was performed of 12 patients with unilateral frontal sinus opacification due to irreversible frontal recess obstruction who underwent FISST. Surgical outcomes were assessed based on symptoms and computed tomography (CT) resolution of frontal sinus disease., Results: All 12 patients undergoing FISST had significant improvement in their symptoms. Ten postoperative CT scans were available for review, all showing continued patency of the interfrontal connection, and nine out of 10 with resolution of radiographic frontal sinus disease. Eleven of the procedures were performed via trephination, and one was achieved endoscopically., Conclusions: In patients with one obstructed frontal sinus and a functional contralateral sinus, removal of the intersinus septum allows for adequate sinus drainage and significant clinical improvement. The success of FISST may be surprising given knowledge of mucociliary clearance patterns, but may be effective because of the naturally dependent position of the frontal sinus ostium., (Copyright © 2011 The American Laryngological, Rhinological, and Otological Society, Inc.)

Background: Allergic rhinitis (AR) is a common disease that affects approximately one-fifth of the U.S. population. Few studies have evaluated the association between secondhand tobacco smoke (SHS) exposure and the impacts on symptom severity in AR. In this study, we evaluated the association of SHS and AR in a community-based study of adult nonsmokers., Methods: In Washington County, Maryland, 83 subjects with AR (physician diagnosed or reported skin test positive), and 117 nonallergic subjects from the same community were recruited and interviewed. A validated questionnaire was used to assess past and present SHS exposure as well as disease-specific quality of life., Results: SHS was reported in 34/83 allergic subjects. Compared with AR subjects with no SHS exposure, subjects with AR and SHS were more likely to report a family history of chronic sinusitis (p = 0.04) and use nasal decongestants (p = 0.012). There was also a borderline association with reporting more severe nasal obstruction (p = 0.14) and nasal drainage (p = 0.08). Compared with nonallergic subjects, allergic subjects were more likely to report longer SHS exposure currently (adjusted mean difference = 1.6 hours/week; p = 0.01) and 20 years ago (adjusted mean difference = 2.9 hours/week; p = 0.03)., Conclusion: Past and current SHS may be a risk factor for AR. Allergic subjects with SHS exposure were more likely to use nasal decongestants and to report more severe nasal symptoms such as nasal obstruction and nasal drainage than nonexposed allergic subjects.