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Presents a letter to the editor to comment on the article "Bronchoscopy for atelectasis in the ICU: A case report and review of the literature," by Mary Elizabeth Kreider and David A. Lipson in the July 2003 issue of the "Chest" journal.

Background: Empty nose syndrome (ENS) is a poorly understood, debilitating condition affecting a minority of patients who underwent nasal airway surgery, most commonly following inferior turbinate surgery. Few publications have demonstrated middle turbinate resection (MTR) causing ENS, but MTR is still considered a potential cause of ENS. The Empty Nose Syndrome 6-item Questionnaire (ENS6Q) is validated for ENS diagnosis, with ENS6Q ≥ 11 considered highly suggestive of ENS. The purpose of this multicenter study was to determine the incidence of patients with ENS6Q ≥ 11 following subtotal MTR during endoscopic sinus surgery (ESS) for chronic rhinosinusitis with nasal polyps (CRSwNP) by comparing preoperative and postoperative ENS6Q scores., Methods: A multi-institutional prospective cohort study (8 US institutions) was conducted on patients who underwent bilateral subtotal MTR during ESS for CRSwNP. Preoperative and postoperative ENS6Q scores were compared after at least 12 months of postoperative follow-up., Results: Of 110 patients, mean age was 51.6 years and 59.1% were male. Mean follow-up was 14.5 ± 2.5 months (range 12.1-22.3 months). Mean preoperative and postoperative ENS6Q were 7.7 and 2.2, respectively, demonstrating a mean 5.5 point decrease postoperatively (p < 0.0001). At final follow-up, no patient had an ENS6Q ≥ 11. Of note, 20% of patients had preoperative ENS6Q scores ≥11, but all decreased to <11 postoperatively., Conclusions: Based on prospective multicenter data over 1-2 years postoperatively, subtotal MTR for CRSwNP never led to ENS6Q scores ≥11, and patients experienced significant decreases in ENS6Q postoperatively. Subtotal MTR during ESS for CRSwNP was, therefore, unlikely to cause ENS even with long-term follow-up., Level of Evidence: 4 Laryngoscope, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: The endoscopic modified Lothrop procedure (EMLP) has become a frequently utilized procedure in rhinologic surgery. One of the most serious complications of the procedure is cerebrospinal fluid leak, which may occur due to lack of recognition of the anterior skull base in the region of the first olfactory filum (FOF), or direct injury to the FOF itself., Objectives: To evaluate the position of the head of the middle turbinate (MT) relative to the FOF, which is an important landmark in the EMLP., Methods: A series of previously obtained patient computed tomography scans of the sinus were reviewed. A reproducible process was implemented to obtain the measurements. First, the FOF was identified on an axial series. Using a localization feature of the radiographic software, this anteroposterior (AP) position could be visualized in a coronal plane. Subsequently, the MT was viewed in a sagittal plane, where a measurement between the head of the MT and the AP position of the FOF could be performed., Results: The AP distance between the head of the MT and the FOF was measured in 92 patients. The head of the MT was either at or anterior to the FOF in all measured subjects. The mean anterior distance of the head of the MT to FOF was 3.6 mm (±2.4 mm) on the right, and 3.8 mm (±2.2 mm) on the left. The range in AP distance was 0 to 12 mm. There was no significant difference in AP distance between the head of the MT and FOF based on gender ( P  = .413) or diagnosis ( P  = .254)., Conclusions: In our study, the head of the MT was reliably at or anterior to the FOF in all subjects, suggesting its utility as a fixed landmark in endoscopic sinus surgery, particularly in the EMLP., Level of Evidence: N/A., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Key Points: Eustachian tube recanalization is a feasible procedure but additional studies are needed to determine its safety. Eustachian tube closure can result from different etiologies and can cause severe symptoms. Ureteral stents have appropriate shape and pliability for placement and long-term healing. Multidisciplinary team approach allows for simultaneous endonasal and otologic approaches., (© 2023 ARS-AAOA, LLC.)

Objectives: Investigate the use of nasal endoscopy, sinus imaging, and neurologic evaluation in patients presenting to a rhinologist primarily for craniofacial pain., Methods: This was a retrospective analysis of consecutive outpatients presenting to a rhinologist between 2016 and 2019 with chief complaints of craniofacial pain with or without other sinonasal symptoms, who were then referred to and evaluated by headache specialists. Data analyzed included sinusitis symptoms, Sino-Nasal Outcome Test (SNOT-22) scores (and facial pain subscores), pain location, nasal endoscopy, computed tomography (CT) findings, and headache diagnoses made by headache specialists., Results: Of the 134 patients with prominent craniofacial pain, the majority of patients were diagnosed with migraine (50%) or tension-type (22%) headache, followed by multiple other non-sinogenic headache disorders. Approximately 5% of patients had headaches attributed to sinusitis. Amongst all patients, 90% had negative nasal endoscopies. Patients with negative endoscopies were significantly less likely to report smell loss ( P  = .003) compared to those with positive endoscopies. Poor agreement was demonstrated between self-reported pain locations and sinus findings on CT (kappa values < 0.20). Negative nasal endoscopy showed high concurrence with negative CT findings (80%-97%)., Conclusions: Patients presenting with chief complaints of craniofacial pain generally met criteria for various non-sinogenic headache disorders. Nasal endoscopy was negative in 90% of patients, and CT demonstrated poor agreement with pain locations. Nasal endoscopy and CT shared high concurrence rates for negative sinus findings. The value of nasal endoscopy over sinus imaging in craniofacial pain evaluation should be explored in future studies.

Background  Numerous methods have been described to repair nasal cerebrospinal fluid (CSF) leaks. Most studies have focused on optimizing CSF leak repair success, leading to closure rates of 90 to 95%. Objective  This study aimed to determine if excellent reconstruction rates could be achieved without using sinonasal packing. Methods  A prospective case series of 73 consecutive patients with various CSF leak etiologies and skull base defects was conducted to evaluate reconstruction success without sinonasal packing. The primary outcome measure was postoperative CSF leak. Secondary outcome measures were postoperative epistaxis requiring intervention in operating room or emergency department, infectious sinusitis, and 22-item sinonasal outcome test (SNOT-22) changes. Results  Mean age was 54.5 years and 64% were female. Multilayered reconstructions were performed in 55.3% of cases, with collagen or bone epidural inlay grafts, and nasal mucosal grafts or nasoseptal flaps for onlay layers. Onlay-only reconstructions with mucosal grafts or nasoseptal flaps were performed in 44.7% of cases. Tissue sealants were used in all cases, and lumbar drains were used in 40.8% of cases. There were two initial failures (97.4% initial success), but both resolved with lumbar drains alone (no revision surgeries). There were no instances of postoperative epistaxis requiring intervention in the operating room or emergency department. Infectious sinusitis occurred in 2.7% of patients in the first 3 months postoperatively. SNOT-22 did not change significantly from preoperatively to first postoperative visits, then improved over time. Conclusion  Nasal CSF leaks from various etiologies and defect sites were successfully repaired without using sinonasal packing, and patients experienced minimal sinonasal morbidity., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

Background: Olfactory dysfunction (OD) has been reported to impact social interactions. However, the relationship between OD and loneliness has received little attention. The purpose of this study was to determine the association between OD and loneliness, controlling for patient factors., Methods: Subjects without otolaryngic complaints were enrolled and olfactory function was assessed using: Sniffin' Sticks test to measure threshold, discrimination and identification (TDI), Questionnaire of Olfactory Disorders Negative Statements (QOD-NS) and 9 - item Olfactory-Visual Analogue Scale (VAS). Loneliness was assessed using the De Jong Gierveld (DJG) and University of California Los Angeles (UCLA) loneliness scales. Bivariate analysis was performed followed by regression analysis, controlling for confounders., Results: In total, 221 subjects were included with a mean age of 50.5 years (range 20 to 93), 133 (60.2%) females and 161 (72.9%) white. Mean TDI score was 29.3 (7.0) and 49.5% of the cohort was dysosmic. Using DJG, 36.4% of the cohort were classified as lonely, whereas 35.0% were lonely using UCLA. Olfactory measures were significantly associated with DJG, including TDI ( β  = -0.03, p = 0.050), olfactory discrimination ( β  = -0.111, p = 0.005), QOD-NS ( β  = 0.058, p < 0.001) and olfactory-VAS ( β  = 0.032, p < 0.001). UCLA scores were significantly associated with QOD-NS (PR 1.061 [CI 1.018-1.107], p = 0.005) and olfactory-VAS scores (PR 1.027, [CI 1.007-1.049], p = 0.009). After controlling for confounders, the association between DJG and olfactory discrimination, as well as DJG and olfactory-VAS remained significant., Conclusions: In this community-based sample of older adults, both OD and loneliness were common. Those subjects with worse olfactory function were more likely to report loneliness. Further research is necessary to establish causality, as well as explore the role of depression.

Objectives: Prior studies have indicated that olfactory cleft (OC) opacification correlates with olfaction in patients with chronic rhinosinusitis (CRS). However, the results have been unclear in patients without polyps. The purpose of this study was to further explore the relationship between OC opacification, sinus opacification, and olfactory function in patients with CRS., Methods: One hundred and forty-eight patients with CRS were prospectively enrolled across five institutions. Olfactory function was evaluated using the Sniffin' Sticks tests (Burghardt, Wedel, Germany) and the 17-item Questionnaire of Olfactory Disorders (QOD-NS). Computed tomography (CT) scans for each patient were acquired and Lund-Mackay scores recorded. Opacification of the OC was determined using OsiriX MD (Pixmeo, Bernex, Switzerland) and correlated with olfaction scores., Results: A total of 148 CRS patients, 73 CRS without nasal polyps (CRSsNP) and 75 CRS with nasal polyps (CRSwNP), as well as 30 control subjects were enrolled. Overall OC opacification averaged 63.7% in CRS patients and 47.1% in control subjects (P < 0.001). In the overall cohort, OC opacification significantly correlated with threshold, discrimination, and identification (TDI) (r = -0.520; P < 0.001) and QOD-NS scores (r = 0.374; P < 0.001). CRSwNP patients demonstrated a significant correlation between OC opacification and TDI scores (r = -0.464; P < 0.001) but not the CRSsNP group (r = -0.143; P = 0.229). Lund-Mackay score correlated with TDI in both the CRSsNP (r = -0.300; P = 0.010) and CRSwNP (r = -0.271; P = 0.019) groups., Conclusion: CT opacification is associated with olfactory dysfunction differentially based on nasal polyp status. Smell loss in CRSwNP correlated with both OC opacification and Lund-Mackay score, whereas CRSsNP correlated only with Lund-Mackay score, indicating different relationships between olfactory function and local inflammatory processes in these disorders., Level of Evidence: 2 Laryngoscope, 130:2311-2318, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Olfactory dysfunction (OD) is common, affecting an estimated 13 million adults in the United States. Prior studies may underestimate OD prevalence due to use of brief smell identification tests or age-adjusted cutoff values, which concede that it is acceptable for older people to have a decreased sense of smell., Objective: To determine OD prevalence in the healthy community when the goal and expectation is ideal olfactory function, rather than age-based population norms. Secondary goals were to explore factors associated with OD., Methods: Subjects without otolaryngic complaints were recruited from the community surrounding the Medical University of South Carolina. Olfactory-specific information was collected, and olfactory function was assessed using the Sniffin' Sticks test (Burghardt, Wedel, Germany) to measure threshold, discrimination, and identification (TDI). OD was defined as a TDI score < 31. Bivariate analysis and linear regression were used to determine factors associated with OD., Results: In total, 176 subjects were included with mean age of 52 years (range: 20-93), 111 (63%) female, and 127 (72%) white. Mean TDI score was 28.8 (6.9) and OD was present in 94 (53%) subjects. Multivariate linear regression revealed that TDI decreased an average of 1 point every 5 years. TDI was also associated with Mini-Mental Status Examination (MMSE) score, asthma, and gastroesophageal reflux disease. Threshold was associated with age, heart problems, and gastroesophageal reflux disease. Discrimination was associated with age and MMSE scores. Identification was associated with age, heart problems, and anxiety., Conclusions: In a community-based sample, OD affects greater than 50% of subjects. Aging impacts all aspects of olfaction, while the effects of factors such as asthma, MMSE scores, gastroesophageal reflux disease, heart problems, and anxiety may only be evident in specific olfactory subtests.

Objectives: Assess characteristics and outcomes of orbital complications of acute bacterial rhinosinusitis (ABRS) in the pediatric population and evaluate trends over time., Methods: A literature search of pediatric orbital complications was performed in the following databases: Ovid MEDLINE, Scopus, and Cochrane Database of Systematic Reviews. Studies reporting data for at least 10 subjects with orbital complications of sinusitis under 18 years old were included. Studies were grouped by publication year; before 2010 and after and including 2010. Studies that only included patients with subperiosteal abscess (SPA) were grouped in a separate category. Data collected include demographics, Chandler class complications, intra-operative culture, treatment, and outcomes. Meta-analysis of proportion was performed to compare data from studies published before 2010 and data published in 2010 and after., Results: Thirty-five studies met inclusion criteria. No significant difference was observed over time in gender of subjects in the all Chandler complications or SPA only groups (P > 0.72). The proportion of subjects presenting with Chandler IV complications decreased from 6.8% to 2.9% in recent studies (P = 0.019). The proportion of subjects treated surgically decreased from 45.2% to 21.7% in the all Chandler complications group (P < 0.0001) and from 90.0% to 47.9% in the SPA only group, P < 0.0001. The proportion of S. pneumoniae positive cultures decreased from 20.5% to 9.1% (P = 0.02)., Conclusion: The demographics of pediatric patients treated for orbital complications of ABRS in published literature has been stable. Patients reported in more recently published studies are less likely to present with orbital abscess and more likely to receive conservative treatment. The proportion of positive Streptococcus pneumoniae cultures have decreased., Competing Interests: Declaration of competing interest None., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Posterior nasal nerve (PNN) cryoablation has shown promise in improving rhinorrhea due to allergic and nonallergic rhinitis (NAR). Early case series have shown meaningful clinical improvement in 75-80% of patients, but variables predicting PNN cryoablation success have not been studied. The purpose of this study was to evaluate whether disease features and ipratropium nasal spray response predicted rhinorrhea response after PNN cryoablation., Methods: A multi-institutional retrospective case-control study of 55 patients who underwent PNN cryoablation for bilateral rhinorrhea due to allergic, nonallergic, or mixed rhinitis was conducted at 3 tertiary medical centers. Patients received a 1-month trial of ipratropium spray. Runny Nose Scores (RNSs) of 0-5 from the 22-item Sino-Nasal Outcome Test were collected prospectively, before and after PNN cryoablation., Results: The mean age of subjects was 55.3 years and 54.6% were women. Mean follow-up was 170 days. NAR comprised 62% of patients. Of the 48 patients who trialed ipratropium spray, 33 (69%) had some response and 15 (31%) had no response. Mean overall preprocedural RNS was 4.2 ± 1.0. After PNN cryoablation, there was a ≥1-point decrease in RNS in 39 patients (71%). Only ipratropium spray (INS) response predicted cryoablation success. For ipratropium spray responders, 28 of 33 (85%) had improved RNS after cryoablation, whereas 5 of 15 (33%) nonresponders improved (p = 0.001)., Conclusion: In chronic rhinitis patients, rhinorrhea response to ipratropium was predictive of rhinorrhea improvement after PNN cryoablation. This study has important implications for preoperative counseling and guiding patient expectations when considering PNN cryoablation., (© 2020 ARS-AAOA, LLC.)

Background: Inverted papilloma (IP) is a benign epithelial tumor of the sinonasal cavity that is locally aggressive and has a propensity for recurrence. Tumors involving the anterior maxillary sinus can be challenging to reach endoscopically, and have historically been approached through a Caldwell-Luc or canine fossa trephination. We present a case series of 22 patients with maxillary IPs originating from the anterior wall, which were successfully resected using a modified endoscopic Denker (MED) procedure. This technique enables access to the entire maxillary sinus without the need for a separate transseptal or sublabial incision., Methods: A retrospective chart review was performed on patients who underwent the MED approach for management of maxillary IPs involving the anterior wall from 2012 to 2018. The demographic data, clinical presentation, radiographic findings, pathology, and surgical outcomes were reviewed., Results: Twenty-two patients were identified, including 13 males and 9 females. Eighteen of the 22 patients had prior surgery and all had Krouse stage 3 disease. After a mean follow-up of 24 (range, 4-63) months, only 1 patient (4.5%) developed a recurrence, which was treated successfully with endoscopic resection. Complications included 1 patient with preoperative epiphora who required dacryocystorhinostomy, epistaxis in another, and 1 patient with transient upper lip numbness. No patients developed alar notching or pyriform aperture stenosis., Conclusion: The MED technique is highly effective for surgical resection of primary and recurrent maxillary IPs involving the anterior wall, providing complete access to the entire maxillary sinus. In many cases, the MED can obviate the need for an adjunctive sublabial or transseptal incision, while also providing excellent exposure for postoperative surveillance., (© 2020 ARS-AAOA, LLC.)

Background: Chronic rhinosinusitis (CRS) is one of the most common causes of olfactory loss, but the pathophysiology underlying olfactory dysfunction in CRS has not been fully elucidated. Previous studies found correlations between olfactory cleft (OC) inflammatory cytokines/chemokines and olfaction in CRS. The purpose of this study was to evaluate the relationship between OC mucus inflammatory proteins and olfaction in a multi-institutional cohort., Methods: Adults with CRS were prospectively recruited. Demographics, comorbidities, olfactory assessment (Sniffin' Sticks), computed tomography (CT), and OC mucus for protein analysis were collected. Statistical analysis was performed to determine associations between olfactory function, OC mucus protein concentrations, and CT opacification., Results: Sixty-two patients were enrolled in the study, with an average age of 48.2 (standard deviation, 16.2) years, and 56.5% were female and 59.7% were classified as CRS with nasal polyps (CRSwNP). Ten of 26 OC mucus proteins were significantly correlated with threshold, discrimination, and identification (TDI) scores and OC opacification. Subgroup analysis by polyp status revealed that, within the CRSwNP group, C-C motif ligand 2 (CCL2), interleukin-5 (IL-5), IL-6, IL-13, IL-10, IL-9, tumor necrosis factor-α (TNF-α), CCL5, and CCL11 were significantly correlated with olfaction. For CRS without nasal polyps (CRSsNP), only C-X-C ligand 5 (CXCL5) showed a correlation. In CRSwNP, IL-6, IL-10, vascular endothelial growth factor-A, and immunoglobulin E (IgE) correlated with OC opacification, whereas, in CRSsNP, only CXCL5 showed a correlation. OC mucus proteins and Lund-Mackay score correlated only in the CRSsNP group (CXCL5, IL-5, IL-13, IgE)., Conclusion: Several OC mucus proteins have been found to correlate with olfactory function and OC opacification. The profile of OC mucus proteins differs between CRSsNP and CRSwNP subgroups, suggesting different mechanisms between groups, but further study is required., (© 2019 ARS-AAOA, LLC.)

Background: Surgical treatment of chronic rhinosinusitis with nasal polyposis (CRSwNP) has evolved over the last decade as rhinologists have increasingly used topical steroid therapies and altered surgical techniques. It is important to understand the changes in success rates of surgery and frequency of revision endoscopic sinus surgery (ESS) in CRSwNP. The aim of this study was to retrospectively review the revision surgical rate of CRSwNP patients by evaluating outcomes in a cohort from the Medical University of South Carolina (MUSC)., Methods: Retrospective review of CRSwNP patients operated upon at the MUSC between 2002 and 2019 by a single surgeon was performed. Assessed factors included demographics, comorbidities, CRSwNP subtype, extent of surgery, and steroid rinse compliance. Logistic regression was performed to identify factors associated with revision surgery., Results: Among 338 patients with at least 6 months of follow-up, 24.9% had revision surgery, with a mean follow-up of 52.6 months. In patients with any person-time measure, the revision rate was 5.58 per 100 person-years. Independent risk factors associated with increased odds ratio (OR) for revision surgery were: younger age (OR, 1.1); prior surgery (OR, 3.3); longer follow-up (OR, 1.1); and surgery before 2009 (OR, 2.4) (p < 0.05 for all)., Conclusion: The revision surgery rate for CRSwNP was 24.9% among those with at least 6 months of follow-up. Risk factors for higher revision rates included younger age, previous surgery, longer follow-up, and surgery at the MUSC prior to 2009. As we enter an era of personalized medicine, it is important to consider patient- and surgeon-specific factors, which impact revision surgery rates., (© 2020 ARS-AAOA, LLC.)

Background: Wide variations in revision endoscopic sinus surgery (ESS) rates for chronic rhinosinusitis with nasal polyposis (CRSwNP) have been reported. It is important to understand expected revision rates and factors that impact the need for revision., Methods: A literature search was conducted on PubMed, Scopus, and the Cochrane Database of Systematic Reviews. Following PRISMA guidelines, a systematic review and meta-analysis was performed on studies that reported revision surgery data for CRSwNP patients., Results: Forty-five studies with 34,220 subjects were meta-analyzed, with an overall revision rate of 18.6% (95% confidence interval, 14.1%-23.6%). Studies with extractable follow-up data reported a mean revision rate of 16.2% over a weighted mean follow-up of 89.6 months. Factors associated with increased revision rates included allergic fungal rhinosinusitis (28.7%), aspirin-exacerbated respiratory disease (27.2%), asthma (22.6%), prior polypectomy (26.0%), and publication prior to 2008 (22.7%) (p < 0.05 for all)., Conclusion: Although polyps can recur after ESS, reported long-term ESS revision rates are approximately 14% to 24%. Identifying risk factors for revision surgery can help manage patient expectations and determine optimal personalized treatments., (© 2019 ARS-AAOA, LLC.)

Background: Olfactory dysfunction (OD) is a common problem, affecting up to 20% of the general population. Previous studies identified olfactory cleft mucus proteins associated with OD in chronic rhinosinusitis (CRS) but not in a healthy population. In this study we aimed to identify olfactory cleft mucus proteins associated with olfaction in individuals without sinus disease., Methods: Subjects free of sinus disease completed medical history questionnaires that collected data regarding demographics, comorbidities, and past exposures. Olfactory testing was performed using Sniffin' Sticks, evaluating threshold, discrimination, and identification. Olfactory cleft mucus (OC) and, in select cases, inferior turbinate mucus (IT) were collected with Leukosorb paper and assays performed for 17 proteins, including growth factors, cytokines/chemokines, cell-cycle regulators, and odorant-binding protein (OBP)., Results: Fifty-six subjects were enrolled in the study, with an average age of 47.8 (standard deviation [SD], 17.6) years, including 33 females (58.9%). The average threshold/discrimination/identification (TDI) score was 30.3 (SD, 6.4). In localization studies, OBP concentrations were significantly higher in OC than IT mucus (p = 0.006). Cyclin-dependent kinase inhibitor 2A (CDKN2A/p16INK4a), basic fibroblast growth factor (bFGF), chemokine ligand 2 (CCL2/MCP-1), granulocyte macrophage colony-stimulating factor (GM-CSF), and chemokine ligand 20 (CCL20/MIP-3a) all inversely correlated with overall TDI (all rho ≥ -0.479, p ≤ 0.004). Stem cell factor (SCF) correlated positively with overall TDI (rho = 0.510, p = 0.002)., Conclusion: Placement of Leukosorb paper is relatively site-specific for olfactory proteins and it is feasible to collect a variety of olfactory cleft proteins that correlate with olfactory function. Further study is required to determine mechanisms of OD in non-CRS subjects., (© 2019 ARS-AAOA, LLC.)

Background: Chronic rhinosinusitis (CRS) is a common condition that has been associated with cognitive dysfunction. The purpose of this study was to evaluate the effect of endoscopic sinus surgery (ESS) on the subjective and objective measures of cognitive dysfunction and related quality-of-life measures in CRS., Methods: Thirty-five adults with CRS refractory to medical therapy were prospectively enrolled. Preoperatively and postoperatively (≥4 months), subjects completed objective neurocognitive evaluation with the Automated Neuropsychological Assessment Metrics (ANAM) platform and multiple questionnaires, including the Cognitive Failures Questionnaire (CFQ), a modified World Health Organization Health and Work Performance Questionnaire (ctHPQ), 22-item Sino-Nasal Outcomes Test (SNOT-22), Sinus Control Test (SCT), Questionnaire of Olfactory Disorders (QOD), Beck Depression Inventory-second edition (BDI-II), Pittsburgh Sleep Quality Index (PSQI), and Fatigue Severity Scale (FSS)., Results: Thirty-three of 35 patients satisfactorily completed the study. Postsurgical improvement in the CFQ was 46.7 ± 18.4 to 31.9 ± 17.8 (p < 0.001). Neurocognitive testing revealed significant improvements in mathematical processing (p = 0.003) and matching to sample (p = 0.023), as well as a significant decline in simple reaction time (p = 0.026). In addition, improvements were noted for SNOT-22 (54.8 ± 21.4 to 24.8 ± 21.1, p < 0.001), SCT (9.3 ± 2.6 to 3.9 ± 3.8, p < 0.001), PSQI (10.7 ± 4.5 to 6.9 ± 4.0, p < 0.001), BDI-II (14.0 ± 9.9 to 8.9 ± 9.0, p < 0.001), QOD (17.6 ± 13.4 to 9.9 ± 12.3, p = 0.001), and FSS (4.6 ± 1.4 to 3.1 ± 1.5, p < 0.001). There was significant improvement in overall presenteeism (7.3 ± 1.4 to 8.4 ± 1.3, p = 0.029). Analysis by polyp status revealed significant improvement in mathematical processing and matching to sample in only CRS patients without polyps., Conclusion: ESS is associated with improvement in subjective and some aspects of objective cognition., (© 2019 ARS-AAOA, LLC.)

Background: Staphylococcus pseudintermedius is a Gram-positive bacteria that colonizes the skin and orifices of healthy canines and felines. It has recently been identified as a cause of sinonasal infections in humans., Methods: This study was a retrospective review of chronic rhinosinusitis (CRS) patients with S pseudintermedius-positive sinonasal cultures and comparison to a prospectively collected control sample of patients who underwent culture for acute exacerbation of CRS., Results: Thirty-three patients with CRS had nasal cultures positive for S pseudintermedius. Of the positive cultures, 82% demonstrated resistance to penicillin, 58% to clindamycin, 45% to trimethoprim-sulfamethoxazole, 33% to doxycycline, and 27% to oxacillin. Ninety-seven percent of patients with S pseudintermedius were dog owners. There was no significant difference in age, gender, recent endoscopic sinus surgery, or immunosuppression or deficiency between S pseudintermedius patients and patients undergoing culture for acute exacerbation of CRS, but S pseudintermedius infection was associated with dog ownership (p < 0.01). S pseudintermedius infection was not associated with behaviors such as a dog sleeping in the bedroom, routinely licking humans, or being diagnosed with a soft tissue infection., Conclusion: Although a rare cause of infection in humans, S pseudintermedius should be considered in sinonasal infections refractory to standard medical management, especially if the patient has regular contact with dogs. S pseudintermedius is not readily identified with routine laboratory diagnostic testing and often demonstrates multidrug resistance, making it a pathogen that is commonly misdiagnosed and difficult to treat., (© 2019 ARS-AAOA, LLC.)

Objectives/hypothesis: To describe rates of complications and mortality within 30 days of open anterior skull base surgery using a large, multi-institutional outcomes database., Study Design: Retrospective cohort study., Methods: The study included patients who underwent open anterior skull base surgery as listed in the American College of Surgeons National Surgical Quality Improvement Project database from 2007 through 2014., Results: A total of 336 open anterior skull base surgeries were identified. One hundred nine (32.4%) patients experienced a complication, reoperation, or mortality. The most common events were postoperative transfusion (15.8%), reoperation (10.1%), and readmission (8.0%). Significant independent predictors of any adverse event included higher American Society of Anesthesiologists (ASA) score and increased total operative time (both P < .05). The only predictor of mortality was higher ASA score (P = .02). Predictors of increased hospital stay included impaired sensorium (P = .04), coma >24 hours (P < .001), lower preoperative hematocrit (P = .02), higher ASA score (P = .04), and increased total operative time (P < .001)., Conclusions: Open anterior skull base surgery is understandably complex, and is thus associated with a relatively high adverse event rate. Knowledge of factors associated with adverse events has the potential to improve preoperative optimization of controllable variables and translate into improved surgical outcomes for patients., Level of Evidence: NA Laryngoscope, 129:1407-1412, 2019., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives  Prolactinomas are the most common functional pituitary adenoma. Symptoms of a prolactinoma stem from hormonal causes (menstrual irregularities, galactorrhea, and reduced libido) or from tumor mass effect (visual changes and headache). Gender differences have been noted in prolactinomas, with males presenting with larger tumors and sequelae of mass effect, while females present commonly with hormonal symptoms. The purpose of this study is to evaluate differences in patient and disease characteristics, and outcomes between male and female prolactinoma patients undergoing surgery. Design  This was a retrospective chart review. Setting  This was done at the tertiary medical center. Participants  The medical records of prolactinomas patients who underwent endoscopic endonasal surgery between March 2008 and August 2016 were reviewed. Main Outcome Measures  Demographic information, tumor characteristics, and treatment characteristics and outcomes were collected. Statistical analysis was performed using chi-squared test or Student's t -test as applicable. Results  Seventy-nine patients were identified, 22 males and 57 females. The average age for males was 38 years and for females was 35 years. Males were more likely to present with decreased libido ( p  < 0.0001), whereas females more often presented with galactorrhea ( p  < 0.0001) and menstrual irregularities. Tumor size was larger in males ( p  = 0.0044) with higher likelihood of suprasellar extension ( p  = 0.0409) and cavernous sinus invasion ( p  = 0.0026). Males were more likely to have a subtotal resection rather than gross total resection ( p  = 0.0086) and less likely to have normalization of prolactin levels following surgery ( p  = 0.0019) Conclusion  Male prolactinoma patients tend to have larger tumors with more aggressive features. This may have a role in the differences in outcomes noted in this study.

Purpose: Pituitary tumors are the second most common intracranial tumors, however, pituitary carcinoma is a rare clinical entity which represents only 0.1-0.2% of all pituitary tumors. Diagnosis of pituitary carcinoma requires the presence of metastasis. Early identification of pituitary carcinoma is difficult, and only recently have guidelines been published for the treatment of aggressive pituitary tumors. We present two cases from our institution, with a review of other cases available in literature in order to better characterize this rare disease., Methods: A retrospective review of two patients with pituitary carcinoma treated at a tertiary medical center was performed. The MEDLINE database was searched for all cases of pituitary carcinoma. Information for age at diagnosis, sex, pituitary tumor type, latency period from pituitary tumor to presentation of carcinoma, sites of metastasis, number of surgical therapies, radiation and chemotherapy, and survival after diagnosis were collected., Results: A total of 69 studies were available for review for a total of 72 unique cases. The average age at diagnosis was 46.3 years. The most common tumors were ACTH-secreting (34.7%), Prolactin-secreting (23.6%), and Null Cell (15.3%). The average latency period from pituitary tumor diagnosis to metastasis was 9 years. All patients underwent surgical therapy during their treatment, with an average of 2.76 procedures. The mortality rate was 54.8% with average time to death after diagnosis of approximately 10 months., Conclusions: Pituitary carcinoma is a rare disease with high mortality rate and is a diagnostic and treatment challenge. Further study is required but is difficult due to its low incidence.

Objectives/Hypotheses  To assess quality of life (QOL) after transnasal, endoscopic pituitary surgery using the 36-item short form (SF-36) instrument. Design  Retrospective review was used for this study. Setting  The study was conducted in a tertiary academic medical center. Participants  Patients who underwent endoscopic, transnasal, transsphenoidal surgery for pituitary adenomas between January 1, 2007 and July 1, 2016 and completed preoperative and postoperative SF-36 surveys. Main Outcome Measures  SF-36 survey data as measured by its eight domains (physical functioning, physical role functioning, emotional role functioning, energy/fatigue, emotional well-being, social functioning, pain, and general health). Results  There were 18 preoperative, 13 short-term (2 weeks or less after surgery) postoperative, and 14 longer term (>2 weeks after surgery) postoperative surveys. There was no significant difference between preoperative and long-term postoperative SF-36 scores across domains ( p  > 0.05). In comparing short-term postoperative and preoperative scores, tumor size was positively associated with emotional well-being ( p  = 0.049) and general health scores ( p  = 0.031), while visual changes preoperatively were positively associated with general health scores ( p  = 0.046). Compared with standard U.S. general population summary data, these patients scored lower preoperatively in all domains except for emotional role functioning and pain ( p  < 0.05). Postoperatively, patients improved to baseline general population data scores with the exception of the physical role functioning domain ( p  < 0.0001). Conclusion  Patients undergoing endoscopic, transnasal, transsphenoidal surgery for pituitary adenomas had lower QOL in six of eight domains preoperatively, but improved to baseline values on the long run after surgery in seven of eight domains. This suggests that minimally invasive pituitary surgery has a restorative role in general QOL as measured by the SF-36.

Objectives/Hypotheses  The endoscopic endonasal approach (EEA) is the workhorse endoscopic procedure for sellar and parasellar pathology. Various reconstruction techniques have been reported following EEA surgery, ranging from no reconstruction to vascularized flaps. We review our institution's experience with sellar reconstruction following EEA and propose an evidence-based algorithm. Design  Retrospective review. Setting  Tertiary academic medical center. Participants  Patients who underwent endoscopic EEA surgery for sellar or parasellar pathology between March 1, 2013 and August 31, 2016. Main Outcome Measures  Patient demographic and clinicopathologic data were collected. Outcome measures included intraoperative and postoperative cerebrospinal fluid (CSF) leak rates and extent of resection (gross or subtotal). Results  Three hundred consecutive patients were included. Depending on the presence and grade of intraoperative CSF leak, cases were reconstructed using either a free mucosal graft (FMG) or nasoseptal flap (NSF). Intraoperative and postoperative CSF leak rates were 30.7% and 2.3%, respectively. Multivariable logistic regression found that intraoperative CSF leak was associated with recurrent disease (odds ratio [OR] 2.47, p  = 0.004), with no apparent predictors of postoperative CSF leak. Conclusions  Based on this large series, we propose the following algorithm for sellar reconstruction: FMG for no CSF leak; fat graft + FMG ± rigid fixation for low-grade leaks; and fat graft + NSF ± rigid fixation for high-grade leaks.

Background: Functional endoscopic sinus surgery (FESS) is an effective treatment for chronic rhinosinusitis (CRS). Postoperative management strategies after FESS often vary from surgeon to surgeon. Recent data suggests that nasal saline irrigation following FESS is almost universally recommended; however, patient adherence has not been formally evaluated. The purpose of this study is to evaluate postoperative nasal irrigation practices and its effects on short-term outcomes in post-FESS patients., Methods: Eighty-two patients were followed prospectively following FESS at a tertiary-academic medical institution for 3 postoperative visits. Patients were surveyed on their irrigation practices (start date, frequency, and volume per irrigation per side), and adherence to prescribed antibiotic and steroid regimens. At each visit, 22-item Sino-Nasal Outcome Test (SNOT-22) questionnaires and endoscopic examinations were evaluated by the Lund-Kennedy Endoscopy Score (LKES). Factors evaluated include: patient demographics (age, sex, ethnicity), preoperative Lund-Mackay and SNOT-22 scores, comorbidities, extent of procedure, and use of nasal packing and/or spacers., Results: Adherence to irrigation instructions was 82.9%. Factors significantly associated with compliance with irrigation instructions included younger age (p = 0.0022), prior irrigation (p < 0.0001), revision surgery (p = 0.0014), and non-native English language speaking (p = 0.0095). Patients were more likely to irrigate with larger volumes if they were younger (p = 0.0284), had prior irrigation (p < 0.0001), or had revision surgery (p = 0.0056)., Conclusion: Multiple factors are associated with patient compliance with nasal saline irrigation after FESS. Ethnic and cultural considerations, such as language barriers, should also be considered to improve outcomes. Identification of patients who may be noncompliant could potentially benefit from increased preoperative counseling to improve adherence rates., (© 2017 ARS-AAOA, LLC.)

Purpose: Angiosarcoma of the tongue is an exceedingly rare malignancy of the head and neck. Such lesions can be primary in nature or occur in a previously irradiated field. We examine a series of cases with relation to clinical presentation, diagnosis, management, and outcomes., Materials and Methods: Retrospective chart review of all patients with angiosarcoma of the tongue at a tertiary academic institution yielded a single case between 2005 and 2016. The MEDLINE database was additionally searched for all case series or reports of angiosarcoma arising in the tongue, and pertinent clinical data were extracted., Results: The clinical presentation, disease course, and management of a patient with angiosarcoma of the tongue are presented. Institutional and literature search yielded a total of eight patients with angiosarcoma of the tongue. The most common primary sites were dorsal and lateral oral tongue. Treatment consisted of surgical resection in 63% of cases with adjuvant therapy administered in 75% of cases. Follow-up times varied per patient, but 63% had persistent or recurrent disease and 67% died of or with disease within two years of index presentation., Conclusion: Angiosarcoma of the tongue is a rare and highly aggressive tumor, accounting for fewer than 1% of all head and neck malignancies. The mainstay of treatment is surgical resection with negative margins followed by adjuvant chemoradiation for high-risk features. Due to rarity of the disease, consensus on optimal treatment approach is lacking, and multi-center prospective studies would be helpful to set clinical guidelines., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives/Hypotheses  Functioning pituitary adenomas may produce endocrinopathies such as acromegaly and Cushing syndrome. Both conditions lead to characteristic anatomic variations as a result of hormonally induced abnormal soft tissue deposition. We evaluate the anatomic differences between acromegalics and Cushing disease patients and compare these dimensions to controls. Design  Radiographic review of preoperative magnetic resonance images (MRI) of the pituitary gland. Setting  Tertiary academic medical center. Participants  Patients who underwent transnasal, transsphenoidal surgery for pituitary adenomas found to have acromegaly or pituitary Cushing between January 1, 2007 and September 1, 2015. A total of 15 patients with similar MRIs and no history of pituitary or sinonasal disease were selected as controls. Main Outcome Measures  Dimensions assessed were intercarotid distance; carotid canal width; piriform aperture width; distance from the piriform aperture to the anterior face of the sphenoid; sphenoid sinus height, width, and length; angle from anterior nasal spine to anteroinferior face of sphenoid sinus; choanal height; and nasal cavity height at the level of the vertical segment of the middle turbinate. Sphenoid sinus pneumatization patterns were recorded. Results  There were 30 acromegalics and 31 Cushing disease patients. When compared with controls, both acromegalics and Cushing disease patients had significantly wider piriform apertures and a longer distance from the piriform aperture to the anterior face of the sphenoid sinus ( p  < 0.05). Acromegalics had a significantly less acute angle (19 ± 3 degrees) from the anterior nasal spine to the sphenoid ( p  < 0.05). Cushing disease patients had significantly lower sphenoid sinus length and shorter nasal cavity height ( p  < 0.05). There were no differences in intercarotid distance or carotid canal width. Conclusions  As acromegalics and Cushing disease patients have known anatomic variations, the skull base surgeon should be aware of these differences and adapt their techniques and approaches as needed.

Objectives  The nasoseptal flap (NSF) has become the workhorse for reconstruction in endoscopic endonasal skull-base surgery. The NSF, though useful in reconstruction, may lead to significant donor site morbidity. Published techniques to reduce the donor site morbidity, free mucosal grafts, and septal rotational flaps have shown to reduce crusting and remucosalization times. We present a novel technique utilizing posterior septal mucosa as a free mucosal graft for reconstruction of the anterior septal donor site. The septal mucosal graft is taken from the mucosa overlying the posterior septectomy site of the endonasal approach to skull base tumors. Design  Retrospective chart review. Setting  Single tertiary academic medical center. Participants  All patients who underwent endoscopic endonasal skull-base surgery between November 1, 2014 and August 30, 2015 with free mucosal graft reconstruction of the NSF donor site. Main Outcome Measures  Postoperative graft success. Results  Fifteen patients underwent septal reconstruction using a septal free mucosal graft. There was a 100% graft success rate with near complete remucosalization by 6 weeks postoperatively. Conclusions  The posterior septal free mucosal graft is a simple, reliable method for reconstructing the NSF donor site. The advantages of this technique include utilization of native septal mucosal tissue and middle turbinate preservation.

Objectives  Rathke's cleft cysts (RCC) are benign cystic lesions of the sella resulting from incomplete obliteration of Rathke's cleft. Symptomatic lesions often require surgical decompression, which is often amenable to a transnasal, transsphenoidal (TNTS) approach. We report our experience with marsupialization of RCC and describe a novel technique to promote re-epithelization of the cyst cavity. Design  Retrospective review. Setting  Tertiary academic medical center. Participants  Patients who underwent TNTS for RCC between 2007 and 2015. Main Outcome Measures  Demographics, lesion characteristics, and reconstruction and treatment outcomes. Results  In total, 52 patients were identified. The mean age was 41 ± 18 years. The mean RCC size was 13 ± 5 mm. Intraoperative cerebrospinal fluid (CSF) leak was encountered in 14 (27%) patients; all were repaired. There were six complications (12%) and no deaths. Mean follow-up was 20 ± 18 months, with five (10%) recurrences. RCC size was associated with intraoperative CSF leak ( p  = 0.04). In 12 patients, the marsupialized cyst cavity was lined with a free mucosal graft (FMG) to promote healing and re-epithelialization. Conclusions  The TNTS approach is safe and effective in surgical decompression of RCC. Lining the exposed cyst cavity with an FMG is a simple intervention without added morbidity that may promote formation of an epithelialized tract. Level of Evidence  Not applicable.

Objectives  Bilateral anterior skull base (ASB) defects following endoscopic endonasal tumor resection are most commonly repaired utilizing multilayered reconstruction with a vascularized mucosal flap. Single-layer closure of large ASB defects has been described in the literature but this technique has yet to gain a widespread use. We report our experience with a series of patients who underwent reconstruction of large ASB defects using a single-layer intradural graft, without nasoseptal flaps. We also compared the use of acellular dermal matrix (AlloDerm, LifeCell, Branchburg, New Jersey, United States) or collagen matrix xenograft (Duramatrix, Stryker, Kalamazoo, Michigan, United States) as the graft biomaterial. Design  A retrospective case series. Setting  Tertiary academic medical center. Main Outcome Measures  Postoperative cerebrospinal fluid leak, the number of postoperative debridements, the number of postoperative infections, and time to remucosalization. Results  Two patients were reconstructed with AlloDerm and three with Duramatrix, with all patients receiving postoperative external beam radiation. There were no postoperative cerebrospinal fluid leaks identified in these patients during follow-up. The AlloDerm group showed increased postsurgical crusting, the number of clinically apparent postoperative infections, and an increased time to remucosalization. Conclusions  Single-layer repair without a vascularized mucosal flap is a viable method of skull base repair for large ASB defects. We found repair with Duramatrix was superior, with less graft crusting and infection, requiring fewer debridements.

Purpose of Review: To perform analysis of evidence in current literature on the topic of genetics and chronic rhinosinusitis (CRS), with a particular focus on recent findings in the cystic fibrosis transmembrane regulator (CFTR), genes associated with primary ciliary dyskinesia, and taste receptor T2R38. Other genes that have been found to have association with CRS are also presented and discussed., Recent Findings: Recent studies in CFTR and CRS research have investigated possible CFTR-potentiators for treatment of refractory CRS. The T2R38 gene has been shown to be applicable in the clinical setting with a testable phenotype and may have a role in the prognosis and influencing management strategies of CRS patients. Many genes of the immune system have been studied, with genome-wide association studies and candidate-gene approaches identifying new associations that will need replication and further elucidation., Summary: CRS is a multifactorial disease, with strong evidence of a genetic component in its pathophysiology for some cases. Currently, there are over 70 genes that have been genetically associated with CRS in the past 15 years. Future investigations into genetic causes and predispositions of CRS may allow for improved prognostication and development of disease-prevention strategies as well as novel therapeutic targets.

Background: Transoral robotic surgery (TORS) has facilitated organ-preserving surgery of the larynx. It has also presented a change in the surgical perspective. We performed cadaveric dissections using the robot to highlight the vascular and muscular anatomy of the supraglottic larynx., Methods: Cadaveric specimens underwent injection of their vasculature, and after injection a robotic surgical system was used to perform a transoral dissection of the supraglottic region. Care was taken to preserve anatomic landmarks and microvascular structures., Results: Five fresh frozen cadaveric human heads were injected with silicone and used for the dissection. The superior laryngeal neurovascular bundle was identified and an absent superior laryngeal vein (SLV) was noted on 1 specimen. Using the robotic endoscope allowed us to visualize and identify the microvasculature of the head and neck., Conclusion: These dissections revealed anatomic variations in the superior laryngeal neurovascular bundle and also highlighted the differences in view using a surgical robotic system., (Copyright © 2013 Wiley Periodicals, Inc.)

Importance: The incidence of thyroid cancer has been steadily increasing; however, no clear reason for the increase in incidence has been identified., Objectives: To compare incidentally discovered (ID) thyroid cancer via non-thyroid-related imaging with nonincidentally discovered (NID) thyroid cancer, as well as determine if differences in tumor characteristics and patient presentation in ID thyroid cancer may help elucidate the increasing incidence of this disease., Design, Setting, and Participants: Retrospective medical record review at an academic tertiary care medical center of 31 patients with ID thyroid cancer and 207 patients with NID thyroid cancer evaluated at our institution during a 12-month period., Main Outcomes and Measures: Patient demographics, tumor pathology, stage, tumor size, invasion, and metastasis were recorded., Results: Mean age at diagnosis was 56.4 years for the ID group and 41.8 years for the NID group (P < .001). The ID group was 54.8% male compared with 13.5% in the NID group (P < .001). The ID group had higher stage disease compared with the NID group (P = .003). There was no difference in tumor size (P = .91), invasion (P = .76), lymph node involvement, or distant metastases (P > .99)., Conclusions and Relevance: Patients with ID thyroid cancer tend to be older at presentation, have higher stage disease, and are more likely to be male compared with patients with NID thyroid cancer. There does not appear to be a significant difference in the size, pathology, or behavior of the tumor at presentation between ID and NID thyroid cancers. These findings imply that improved detection may not represent the only cause of the increased incidence of thyroid cancer.