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SMARCB1(INI-1)-deficient sinonasal carcinoma is a rare, poorly differentiated neoplasm with a poor prognosis. Though historically most were identified as sinonasal undifferentiated carcinoma, we now understand it to be a distinct entity. There is currently a general consensus supporting multimodal therapy, though the optimal sequence of surgery, chemotherapy, and radiation has yet to be defined.

To review the various factors associated with the most common cause of maxillary sinus dysfunction; recalcitrant chronic maxillary sinusitis (RCMS). In addition, available medical and surgical management options are discussed along with various tips and tricks for optimal management.Defects in mucociliary clearance, immunodeficiency, anatomic factors, and infectious etiologies have been implicated in dysfunction of the maxillary sinus leading to RCMS. Medical management including oral antibiotics or topical drugs have shown varying degrees of success. Endoscopic modified medial maxillectomy (EMMM) has been shown to significantly improve symptoms in patients with RCMS.A dysfunctional maxillary sinus presents a clinical challenge. A thorough evaluation of any potential contributing factors must be done in addition to an assessment of the adequacy of prior surgical treatment of the maxillary sinus. Beyond the middle meatal antrostomy, EMMM can be used to effectively address RCMS. In cases that fail EMMM, removal of the condemned mucosa to encourage auto-obliteration of the sinus can be considered.

BACKGROUND Social determinants of health (SDoH) include the socioeconomic, demographic, and social conditions that influence differences in health status among individuals and groups. The impact of these conditions on olfactory function remains poorly understood. In this scoping review, we systematically review the available literature to synthesize the association between SDoH and olfactory function. METHODS In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Review (PRISMA-ScR) guidelines, we performed systematic search queries in PubMed, Embase, and Ovid databases and categorized articles according to themes that emerged regarding SDoH. The primary outcomes included self-reported and objective measurements of smell. RESULTS We identified 722 unique references that underwent title and abstract review by two independent reviewers, with 70 articles undergoing full-text review and 57 relevant for data extraction. Six themes emerged in our review, under which we categorized the studies and synthesized respective associations with olfactory function. These include studies exploring socioeconomic status (n = 19, 33%), education status (n = 27, 47%), occupational exposures (n = 26, 46%), racial/ethnic disparities (n = 12, 21%), and lifestyle/behavioral factors (n = 33, 58%). CONCLUSIONS Within the context of this scoping review, olfactory dysfunction is significantly more prevalent in patients with lower socioeconomic status, exposure to environmental and occupational toxins, and of minority race/ethnicity, whereas the associations between olfactory dysfunction and education level and lifestyle factors such as smoking and drinking seem to be much more elusive. This review highlights the importance of accounting for SDoH in observational studies examining olfactory outcomes. Given the increased awareness of olfactory loss, special consideration should be given to understanding olfactory dysfunction in the context of these factors.

The medical malpractice system in the United States intends to make healthcare safer by serving three functions: deter negligence, compensate plaintiffs injured by negligence, and promote corrective justice to rectify wrongfulness caused by negligence. However, the current system is widely regarded as inefficient, ineffective, and costly. This chapter first provides an overview of the historical evolution of the medical liability system. We then discuss its various costs not only to the healthcare system but also to patients and physicians. We examine the emergence of defensive medicine and the effects of malpractice on physicians’ mental health as well as on patients’ access to healthcare and the overall quality of healthcare received. Finally, this chapter summarizes past and present malpractice tort reform legislation and its influence on the healthcare system.

The field of rhinology continues to evolve after the introduction of endoscopic sinus surgery in the 1980s. Despite advancements in technology, the close proximity of the sinonasal cavity to critical neurovascular structures allows for the possibility of major complications. Complications that have been cited in malpractice proceedings include anosmia, cerebrospinal fluid leak due to skull base injury and resultant meningitis, intraorbital injury including orbital hematoma, and even death. Due to the significant impact these complications have on patients’ lives, rhinology remains the most litigated subspecialty within Otolaryngology, and payments in malpractice cases can be substantial. In addition to surgical complications, proper informed consent remains a critical factor in many litigation cases. The field continues to evolve rapidly with increasing use of technologies such as balloon sinusotomy and with physicians diverting rhinologic procedures to an office-based setting. However, the same overall themes of appropriate physician–patient communication, comprehensive informed consent, and avoiding unnecessary risks should be considered essential. It often takes many years for cases to proceed from initial injury to medicolegal proceedings and eventually to publicly available court records. Consequently, the impact of many of these changing practice patterns on litigation in rhinology is still unknown. In this chapter, we review the evolution of malpractice within rhinology and highlight strategies to mitigate litigation risk in a rhinologic practice.

Informed consent is a critical aspect of the preoperative visit and involves providing relevant information about the surgery, patient comprehension of that information, patient competence to provide consent, and voluntary choice. Risks that are specific to the surgery should be discussed, as well as any significant risks that may influence a patient’s decision. Particular consideration should be given to the use of non-FDA-approved drugs or devices and concurrent surgeries in the informed consent discussion. Lack of informed consent is a commonly cited reason for litigation in Otolaryngology. Otolaryngologists should strive for thorough, meaningful discussions that allow patients to make independent and informed decisions about their care.

Background Squamous cell carcinoma (SCC) is the most common malignancy in the sinonasal tract. We present the first population-based analysis that examines geographic differences in demographic and clinical characteristics, socioeconomic factors, treatment modality, and disease-specific survival (DSS) of this entity. Methods All cases of sinonasal squamous cell carcinoma (SNSCC) were queried using the U.S. Surveillance, Epidemiology, and End Results (SEER) registry from 1973 to 2013. Patients were stratified by geographic location and characteristics such as demographics (age, gender, race, metropolitan/nonmetropolitan status, and income), stage at diagnosis, and treatment modality. Survival data were generated using Kaplan-Meier regression analysis. Results In total, 6094 patients were identified; 15.3% were from the East, 16.3% from the Midwest, 19.3% from the South, and 49.1% from the West. Patients from the South were younger (p < 0.001). The South had the highest proportion of patients who were black (p < 0.001), lived in nonmetropolitan areas (p < 0.001), and presented with localized disease (p < 0.001). Southern patients also had the lowest median income (p < 0.05), and were least likely to be treated with both surgery and radiotherapy (p < 0.001). The South exhibited the lowest 20-year DSS compared to all other regions (p < 0.001). Conclusion SNSCC patients from the South had the poorest long-term DSS, despite being most likely to present with localized disease. The South had the highest proportion of patients who were black, resided in rural or urban towns, had the lowest median income, and did not receive standard combination therapy, compared to the East, Midwest, and West.

Objectives To analyze the demographics, survival, and treatment efficacy of pediatric sarcomas of the facial skeleton and skull. Methods Retrospective study of cases from the US National Cancer Institute's Surveillance, Epidemiology, and End Results database. Pediatric patients between the ages of 0 and 18 diagnosed with a malignant sarcoma of either the mandible or the bones of skull, face, and associated joints from 1973 to 2013 were studied. Results In total, 204 patients were included in the analysis. The average age at diagnosis was 11.39 (±5.15) years with a male-to-female ratio of 1.4:1. Whites were the most commonly affected race (76.0%). Malignant mandible sarcomas accounted for 29.9% of the cohort (n = 61). The most common pathology was osteosarcoma, which accounted for 43.6% of the cohort (n = 89). Among patients with known histologic grade (n = 95), 26.0% were AJCC stage III or IV. Overall, 5-year disease-specific survival (DSS) was 80.6%. When stratified by treatment modality, 5-year DSS was 86.0% for surgery alone, 67.9% for radiation alone, and 75.3% for surgery with adjuvant radiotherapy (p = 0.041). Conclusions Osteosarcoma, Ewing's sarcoma, and chondrosarcoma are the most common subtypes of pediatric head and neck bone sarcoma. Such sarcomas more commonly affect whites and males during pubertal ages. Disease-specific survival is not affected by primary site. Surgery alone is the mainstay of treatment, and demonstrates higher 5-year disease-specific survival compared to radiotherapy alone. Adjuvant radiotherapy does not seem to increase survival, but further investigation is warranted.

Objectives/Hypothesis Although previous studies have reported increased perioperative complications among obstructive sleep apnea (OSA) patients undergoing any surgery requiring general anesthesia, there is a paucity of literature addressing the impact of OSA on postoperative transsphenoidal surgery (TSS) complications. The aim of this study was to analyze postoperative outcomes in transsphenoidal pituitary surgery patients with OSA. Secondarily, we examined patient characteristics and comorbidities. Study Design Retrospective analysis. Methods The 2002 to 2013 National Inpatient Sample was queried for patients undergoing TSS for pituitary neoplasm. Patients with an additional diagnosis of OSA were identified, and compared to a non-OSA cohort. Results There were 17,777 patients identified; 5.0% (N = 889) had an additional diagnosis of OSA. The OSA cohort had more comorbidities including diabetes mellitus, congestive heart failure, chronic pulmonary disease, coagulopathy, hypertension, hypothyroidism, liver disease, obesity, peripheral vascular disease, renal failure, acromegaly, and Cushing's syndrome. Postoperatively, OSA was independently associated with increased risks of tracheostomy (P = .015) and hypoxemia (P < .001), and decreased risk of cardiac complications (P = .034). OSA patients did not have increased rates of cerebrospinal fluid rhinorrhea, diabetes insipidus, reintubation, aspiration pneumonia, infectious pneumonia, thromboembolic complications, or urinary/renal complications. In-hospital mortality rates did not vary between the two cohorts. Conclusions In patients who underwent transsphenoidal pituitary surgery, OSA was associated with higher rates of certain pulmonary and airway complications. OSA was not associated with increased non–pulmonary/airway complications or inpatient mortality, despite older average age and higher comorbidity rates. Level of Evidence 2C Laryngoscope, 2017

Objectives/Hypothesis The head and neck are two of the most common locations for cutaneous melanoma. We present the first population-based analysis of geographic differences in anatomic subsite, clinicopathologic and demographical traits, histopathologic subtype, treatment modality, and disease-specific survival (DSS) of cutaneous head and neck melanoma (CHNM). Study Design Retrospective database analysis. Methods The Surveillance, Epidemiology, and End Results database was queried for cases of CHNM reported between 2000 and 2013. Patients were grouped into East, Midwest, South, and West regions of the United States. Overall incidence, demographic traits, primary tumor site, clinicopathologic traits, histopathologic subtype, treatment modality, and DSS were compared among regions. Results There were 49,365 patients with CHNM identified. The West (4.60) and the South (4.42) had significantly higher incidence (per 100,000) than the East (3.84) and Midwest (3.65) (P < .05). DSS was significantly different among regions (P < .0066). The East (5 years: 89.4%, 10 years: 84.1%) had the highest DSS rate, and the South (5 years: 87.0%, 10 years: 81.8%) had the lowest DSS rate. The Midwest (5 years: 88.4%, 10 years: 84.3%) and West (5 years: 88.3%, 10 years: 83.5%) had intermediate DSS. On multivariate analysis, the South had an elevated hazard ratio (1.17, 95% confidence interval: 1.05-1.30) when compared to the West. Conclusions Geographic region may play a significant role in CHNM. Incidence is higher in the South and the West. Incidence, histologic subtype, treatment modality, and DSS vary among regions. DSS is lower in the South than the West, even after accounting for other major prognostic factors. Level of Evidence 4. Laryngoscope, 2017

Objectives Head and neck sweat gland adenocarcinoma (HNSGA) is an extremely rare malignancy. We present the first population-based analysis regarding this entity. Study Design Retrospective population-based analysis. Methods Using the Surveillance, Epidemiology, and End Results registry from 2000 to 2013, we extracted 627 cases of HNSGA. Data were analyzed for incidence trends, demographic and clinicopathologic traits, and predictors of disease-specific survival (DSS). Results The majority HNSGA cases were white, male, and 60 to 79 years old. The incidence was 0.036 per 100,000 people. Tumors most often presented as localized disease and histological grade II/III. The skin of the face was the most common primary site (43.4%), followed by the scalp and neck (31.6%). Overall 5-, 10-, and 20-year DSS were 94.6%, 89.6%, and 79.8%, respectively. Ethnicity did not affect survival, whereas a younger age at diagnosis and female sex conferred an advantage at 10 years (P = 0.0386) and 5 years (P = 0.0191), respectively. The origin of the HNSGA (apocrine vs. eccrine) did not affect outcomes. Regional and distant disease predicted worse DSS at 5, 10, and 20 years (P = 0.0026, P < 0.001, P < 0.001, respectively). Compared to grade I/II disease, grade III/IV dramatically worsened 5-, 10-, and 20-year DSS (P = 0.0035, P < 0.0001, P = 0.0011, respectively). Scalp and neck HNSGA exhibited the poorest 20-year DSS compared to other primary sites (P = 0.0024). Conclusion We present the largest cohort of HNSGA. Significant poor prognostic indicators include older age, higher tumor grade, greater extent of invasion, and primary site of the scalp or neck. Level of Evidence 4. Laryngoscope, 127:2757–2762, 2017

To (1) analyze postoperative thyroidectomy outcomes in patients with diabetes mellitus (DM), who are prone to deleterious effects of glucose dysmetabolism, and (2) apply findings to optimize perioperative management of diabetics requiring thyroid surgery.Retrospective database analysis.University hospital.The National Inpatient Sample was queried usingIn total, 103,842 cases met inclusion criteria; 14.2% were diabetics. Diabetics had significantly higher rates of baseline comorbid chronic pulmonary disease, hypertension, obesity, and anemia. Following thyroidectomy, patients with DM were more likely to have vocal cord paresis or paralysis compared to non-DM patients (2.0% vs 1.3%;Although DM often confers metabolic and ischemic derangements secondary to hyperglycemia such as neuropathy, this comorbidity was not independently associated with higher rates of vocal cord paresis or paralysis following thyroid surgery. However, DM predicted other adverse outcomes, including greater cardiac, pulmonary, and urinary complications, as well as transfusion, reintubation, and in-hospital mortality.

BACKGROUND Currently, limited literature exists about sinonasal adenoid cystic carcinoma (SNACC). In this study, we analyze the demographics, survival, and treatment efficacy of this rare entity. METHODS Our study was a retrospective population-based analysis of SNACC in the Surveillance, Epidemiology, and End Results (SEER) database assessing the 40-year time-frame of 1973 to 2013. RESULTS Six hundred ninety-four SNACC patients were identified; 53.2% were female and 46.8% were male. Caucasians were most commonly affected (77.1%). SNACC most often arose from the maxillary sinuses, followed by the nasal cavity. The majority of SNACC cases presented as stage IV disease. Nodal and distant metastases were present in 3.6% and 7.1% of all cases, respectively. Overall 5-, 10-, and 20-year disease-specific survival (DSS) rates were 66.5%, 41.1%, and 17.6%, respectively. The presence of distant metastasis dropped the 5-year DSS rate from 64.5% to 20.0%. Cases treated with combined surgery and adjuvant radiotherapy had a slightly improved 5-year DSS rate compared with surgery alone (73.5% vs 72.5%). Surgery alone resulted in higher 10- and 20-year DSS rates (54.2% and 36.8%, respectively) when compared with combined therapy (44.2% and 15.5%), radiotherapy alone (10.8% and 0%), and no surgery or radiotherapy (9.3% and 0%). CONCLUSION This study represents the largest cohort of SNACC patients to date. Factors that confer a survival benefit in SNACC include M0 disease, and presentation primarily in the nasal cavity. Overall low rates of nodal metastasis may not warrant the use of elective neck dissections, unless there is clinical suspicion. Modalities of therapy that include surgery greatly improve survival. Adjuvant radiotherapy appears to slightly improve 5-year disease-free survival but does not impact long-term survival.

Adenoid cystic carcinoma (ACC) is a rare malignant epithelial neoplasm of secretory glands of the upper aerodigestive tract. It accounts for 3-5% of head and neck malignancies and most commonly arises from the minor salivary glands of the oral cavity. The clinical behavior of ACC from specific anatomic subsites, including the oral cavity, is not well described in the literature. We aim to elucidate patient demographics, clinicopathologic features, incidence, and survival trends for oral cavity ACC (OCACC).Retrospective population-based analysis of OCACC in the SEER database between 1973 and 2012.1066 OCACC patients were identified, of which 57.7% were female (P0.0001). Incidence was 0.049 per 100,000. Whites were most commonly affected (81.1%). The hard palate was the most commonly involved subsite (44.1%). Nodal involvement was seen in 8.4% of cases and distant metastasis was present in 6.2% of cases at the time of presentation. Disease-specific survival (DSS) rates at 1, 5, 10, 15, and 20years were 97.4%, 83.9%, 69.9%, 57.6%, and 46.2%, respectively. Females had a higher 5-year DSS (87.8%) than males (78.4%, P=0.0004). Cases treated with surgery had a favorable prognosis regardless of whether they received radiotherapy (P0.0001). Nodal involvement reduced 5-year DSS by 51.6% (P0.0001), while distant metastasis reduced 5-year DSS by 46.4% (P0.0001).OCACC is a rare malignancy with females and whites being more commonly affected. At presentation, regional and distant metastases are uncommon. Poor prognostic indicators include male gender, nonsurgical therapy, nodal involvement, and distant metastasis.

Objectives To examine the occurrence of facial nerve stimulation (FNS) and outcomes in patients with cochlear-facial dehiscence (CFD) who underwent cochlear implantation (CI). Methods The medical charts and imaging of three patients with bilateral sensorineural hearing loss (SNHL) who presented for CI evaluation were reviewed. Results Patient 1 (P1) had a history of Meniere's disease. Patient 2 (P2) had a history of medulloblastoma treated with surgery and chemoradiation. Patient 3 (P3) had a history of progressive SNHL. Audiometry showed moderate-to-severe SNHL in P1, severe-to-profound SNHL in P2, and profound SNHL in P3. All had poor speech discrimination ability. Temporal bone computed tomography (CT) coronal cuts were suspicious for bilateral dehiscence between the superior basal turn of the cochlea and labyrinthine segment of the facial nerve in P2 and P3, with maximum dehiscence lengths of 2.0 mm on the left in P2, and 1.8 mm on the right in P3. A thin bony partition was visualized bilaterally in P1. The left ear of P1, left ear of P2, and right ear of P3 were implanted. Facial nerve stimulation occurred immediately upon activation in P1 and P2, which resolved by decreasing the dynamic range of the offending electrodes. No FNS was observed in P3. Conclusion Cochlear-facial dehiscence can predispose patients to post-implant FNS. Prior temporal bone irradiation may carry a higher risk of FNS. We recommend scrutiny for CFD in CTs of CI candidates and appropriate risk counseling for FNS if CFD is discovered and more frequent monitoring for FNS by audiology.

BackgroundEpistaxis is common in elderly patients, occasionally necessitating hospitalization for the management of severe bleeds. In this study, we aim to explore the impact of nasal packing versus nonpacking interventions (cauterization, embolization, and ligation) on outcomes and complications of epistaxis hospitalization in the elderly.MethodsThe 2008–2013 National Inpatient Sample was queried for elderly patients (≥65 years) with a primary diagnosis of epistaxis and accompanying procedure codes for anterior and posterior nasal packing or nonpacking interventions.ResultsA total of 8449 cases met the inclusion criteria, with 62.4% receiving only nasal packing and 37.6% receiving nonpacking interventions. On average, nonpacking interventions were associated with a 9.9% increase in length of stay and a 54.0% increase in hospital charges. Comorbidity rates did not vary between cohorts, except for diabetes mellitus, which was less common in the nonpacking cohort (26.6% vs 29.0%; P = .014). Nonpacking interventions were associated with an increased rate of blood transfusion (24.5% vs. 21.8%; P = .004), but no significant differences in rates of stroke, blindness, aspiration pneumonia, infectious pneumonia, thromboembolism, urinary/renal complications, pulmonary complications, cardiac complications, or in-hospital mortality. Comparing patients receiving ligation or embolization, no differences in length of stay, complications, or in-hospital mortality were found; however, embolization patients incurred 232.1% greater hospital charges ( P ConclusionNonpacking interventions in the elderly do not appear to be associated with increased morbidity or mortality when compared to nasal packing only but appear to be associated with increased hospital charges and length of stay. Embolization in the elderly results in greater hospital charges but no change in outcome when compared to ligation.