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Background  High-flow skull base dural defects are associated with an increased risk of postoperative cerebrospinal fluid (CSF) leaks. Objective  This study aimed to identify the risk factors for persistent postoperative CSF leak after endoscopic endonasal surgery (EES) and determine the ideal reconstruction strategy after initial failed repair. Methods  Patients with CSF leak after intradural EES between October 2000 and February 2017 were identified. Cases with persistent CSF leak were compared with patients with similar pathologic diagnosis without a persistent leak to identify additional risk factors. Results  Two hundred and twenty-three out of 3,232 patients developed postoperative CSF leak. Persistent leaks requiring more than one postoperative repair occurred in 7/223 patients (3.1%). All seven had undergone intradural approach to the posterior fossa for resection of recurrent/residual clival chordomas. This group was matched with 25 patients with recurrent/residual clival chordoma who underwent EES without postoperative CSF leak (control group). Age, gender, history of diabetes, smoking, or radiotherapy were not statistically different between the groups. Obesity (body mass index > 30) was significantly more common in the group with persistent leak (86%) compared with controls (36%) (p  = 0.02). All patients with a persistent CSF leak developed meningitis (p  = 0.001). Five patients with persistent leak required a pericranial flap to achieve definitive repair. Conclusion  Multiple recurrent CSF leak after EES primarily occurs following resection of recurrent/residual posterior fossa chordoma. Obesity is a major risk factor and meningitis is universal with persistent leak. Flap necrosis may play a role in the development of persistent CSF leaks, and the use of secondary vascularized flaps, specifically extracranial–pericranial flaps, should be considered as an early rescue option in obese patients. [ABSTRACT FROM AUTHOR]

Background: Air pollution directly interacts with airway mucosa, yet little is known about how pollutants affect upper airway inflammation. Studies have shown increased incidence of chronic rhinosinusitis (CRS), rhinitis, and asthma in areas with higher traffic pollution, and these neighborhoods are often associated with lower socioeconomic status (SES). The Area Deprivation Index (ADI) assesses neighborhood‐level SES by zip code. The purpose of this study was to assess the relationship between SES and exposure to inhaled pollutants and CRS disease severity. Methods: CRS patients with and without nasal polyps (CRSwNP and CRSsNP, respectively) were identified (total patients = 234; CRSwNP patients = 138; CRSsNP patients = 96). Pollutant concentrations, including particulate matter 2.5 (PM2.5), black carbon (BC), and nitrogen dioxide (NO2), were measured at 70 sites within the defined countywide sites and used to estimate patient exposures. SES was measured by ADI state deciles. Disease severity metrics included the modified Lund‐Mackay score (LMS), the need for systemic steroids, and functional endoscopic sinus surgery (FESS). Associations were analyzed and identified using linear, logistic, and Poisson multivariable regression. Results: The distribution of CRSsNP and CRSwNP patients across ADI state deciles was similar. ADI, however, was a predictor of exposure to airborne pollutants (PM2.5, BC, and NO2) with a 1.39%, 2.39%, and 2.49% increase in PM2.5, BC, and NO2 per increasing decile increment (p < 0.0001), respectively, which demonstrated a direct correlation between deprived neighborhoods and higher levels of exposure to PM2.5, BC, and NO2 with an increase in pollutant levels per increase in ADI decile. Furthermore, ADI was a predictor for increased steroid treatment. Conclusion: Lower SES predicted higher exposure to air pollution and increased disease severity in patients with CRS as demonstrated by the increased need for steroid treatment. [ABSTRACT FROM AUTHOR]

Background  A nasal access guide (NAG) for endoscopic endonasal approaches (EEAs) to the skull-base has been developed and approved for clinical use but its utility has not been formally investigated. Objective  The study aims to assess the effect of a NAG on endoscopic visualization during cadaveric dissection and to perform a workflow analysis with process-based performance measures in the operating room and their effect on clinical outcomes. Methods  Skull-base course participants were observed during hands-on cadaveric dissection with and without NAG. Instances of endoscope withdrawal for lens cleaning and inadequate visualization due to lens soiling were tabulated. Participants completed a Likert-scale survey examining the NAG utility and provided an overall grading. Surgical workflow and process-based performance on patients undergoing EEA to the skull-base was analyzed. Passage of powered and dissecting instruments, removal of endoscopes for cleaning, and dislodgment or migration of the device were reviewed. Postoperative assessments included mucosal trauma and synechiae formation. Results  Instances of endoscope soiling and manual cleaning were significantly reduced by 40% and 61% with the NAG during cadaveric dissection. The overall grading of the device was 2.75/3. Surgical workflow was observed in 35 patients. Average number of passes of endoscopes, instruments, and powered tools during a 10-minute observation period were 3,17, and 5 during the surgical approach, and 3, 18, and 1 during tumor dissection. Dislodgement of the device occurred in 25.7% and migration of the device in 2.8% of cases. Postoperative synechiae, exposed cartilage or septal perforation was not observed in follow up. Conclusion  NAG can significantly reduce inadequate visualization during EEA to the skull-base and has the potential to reduce instances of nasal trauma. Participants assessed its overall utility as being "excellent." [ABSTRACT FROM AUTHOR]

Background: Previous work has shown that chronic rhinosinusitis (CRS) severity may be associated with particulate matter 2.5 (PM2.5) and black carbon (BC) in CRS patients without nasal polyps (CRSsNP). Data regarding occupational exposures, however, are lacking. We assessed the impact of PM2.5, BC, as well as occupational airborne exposure on CRS disease severity. Methods: Patients with CRS with nasal polyps (CRSwNP), CRSsNP, and aspirin‐exacerbated respiratory disease (AERD) were identified from an institutionwide database. Spatial modeling from 37 pollutant monitoring sites in Allegheny County was used to estimate exposures. Patient occupations using the 2010 Standard Occupation Classification (SOC10) and airborne occupation exposures to vapors, gases, dusts, fumes, fibers and mists (VGDFFiM) or diesel fumes were recorded. Disease severity was measured by modified Lund‐Mackay score (LMS), systemic corticosteroid therapy, and incidence of functional endoscopic sinus surgery (FESS). Results: Two hundred thirty‐four patients were included (CRSwNP, n = 113; CRSsNP, n = 96; AERD, n = 25). The prevalence of AERD among those with CRSwNP was 18%. Patients exposed to VGDFFiM or diesel fumes required higher steroid doses vs nonexposed patients (p = 0.015 and p = 0.03, respectively); patients with VGDFFiM levels >5% were more likely to undergo FESS vs nonexposed patients (p = 0.0378). There was no difference in PM2.5 and BC with regard to disease severity and FESS between CRSwNP, CRSsNP, and AERD patients. Steroid use was significantly higher in CRSwNP and AERD vs CRSsNP (p = 0.001). LMS was significantly higher in AERD as compared with CRSwNP and CRSsNP (p = 0.001). Conclusion: Occupational airborne exposure to VGDFFiM correlated with increased prevalence of FESS and need for corticosteroids in CRS patients. There was no difference in PM2.5 and BC levels and disease severity outcome measures between CRS subtypes in this subset. [ABSTRACT FROM AUTHOR]

Background Empty nose syndrome (ENS) is considered an acquired condition that remains difficult to diagnose objectively. Defining specific symptoms that can be reliably associated with this disorder would be essential to identifying possible ENS patients. We sought to validate an ENS-specific, 6-item questionnaire as an adjunct to the standard Sino-Nasal Outcome Test 22 (SNOT-22) questionnaire to discriminate patients suspected of having ENS. Methods The Empty Nose Syndrome 6-item Questionnaire (ENS6Q) paired 6 common ENS symptoms (nasal suffocation, nasal burning, nasal openness, crusting, dryness, and impaired air sensation through nasal cavities) with testing on 75 patients divided in 3 patient cohorts: ENS; chronic rhinosinusitis without polyposis; and healthy controls. Participants answered 2 rounds of both the SNOT-22 questionnaire and ENS6Q within 48 hours of each other. No changes in treatments occurred in the test interval between questionnaires. Internal consistency, test-retest reliability, validity, and area under the curve were assessed to differentiate between patient cohorts using the 2 instruments. Results We found high internal consistency for ENS6Q and SNOT-22 questionnaire at 0.93 (95% CI, 0.90-0.95) and 0.94 (95% CI, 0.94-0.96), respectively. The test-retest reliability between timepoints for ENS6Q testing was 0.969. The ENS6Q statistically significantly discriminated between ENS and control patients and between ENS and chronic rhinosinusitis without polyposis (CRSsNP) patients, without significant differences between CRSsNP and controls. The area-under-the-curve (AUC) threshold score comparison further supported the ability of the ENS6Q to differentiate ENS from CRSsNP patients. Conclusion The ENS6Q is the first validated, specific, adjunct questionnaire to the SNOT-22 to more reliably identify patients suspected of developing ENS. [ABSTRACT FROM AUTHOR]