Predictors of Sinonasal Improvement After Highly Effective Modulator Therapy in Adults with Cystic Fibrosis

OBJECTIVES

The 22-question SinoNasal Outcome Test (SNOT-22) assesses chronic rhinosinusitis (CRS) severity. We aimed to identify predictors of SNOT-22 score improvement following highly effective modulator therapy (HEMT) initiation and to corroborate the SNOT-22 minimal clinically important difference (MCID) in adults with cystic fibrosis (CF).

METHODS

Prospective observational data was pooled from four studies across 10 US centers investigating people with CF (PwCF) and CRS. Three studies evaluated HEMT's impact on CRS. For participants enrolled prior to HEMT initiation, SNOT-22 scores were obtained at baseline and after 3-6 months of HEMT. Multivariate regression identified predictors of improvement. Cronbach's alpha and four distribution-based methods were used to assess internal consistency and calculate the MCID of the SNOT-22.

RESULTS

A total of 184 PwCF participated with mean baseline SNOT-22 scores ranging from 18.1 to 56.7. Cronbach's alpha was ≥0.90 across sites. Participants at sites with pre- and post-HEMT data reported improvement in SNOT-22 scores after initiating HEMT (all p < 0.05). Worse baseline SNOT-22 score (odds ratio (OR): 1.05, p < 0.001, 95% CI: 1.02-1.08), F508del homozygosity (OR: 4.30, p = 0.040, 95% CI: 1.14-18.99), and absence of prior modulator therapy (OR: 4.99, p = 0.017, 95% CI: 1.39-20.11) were associated with greater SNOT-22 improvement. The mean MCID calculated via distribution-based methods was 8.5.

CONCLUSION

Worse baseline sinonasal symptoms, F508del homozygosity, and absence of prior modulator therapy predicted greater improvement after HEMT initiation. The mean MCID for SNOT-22 in PwCF is 8.5 points, similar to non-CF individuals with CRS, and provides a threshold specifically for PwCF. The SNOT-22 has strong internal consistency in PwCF.

LEVEL OF EVIDENCE

3 Laryngoscope, 2024.

Factors that predict pursuing sinus surgery in the era of highly effective modulator therapy

BACKGROUND

Comorbid chronic rhinosinusitis (CRS) remains unresolved for many people with cystic fibrosis (PwCF). While highly effective modulator therapy improves quality-of-life and symptom severity, the impact of this intervention and other factors associated with pursuing endoscopic sinus surgery (ESS) remains understudied.

METHODS

Adult PwCF + CRS were enrolled into a prospective, observational, multi-institutional study. Participants completed validated outcome measures to evaluate respiratory symptom severity, depression, headache, and sleep quality, as well as nasal endoscopy, sinus computed tomography (CT), and olfactory testing. Bivariate comparisons and regression modeling evaluated treatment cofactors, disease characteristics, and outcome measures associated with pursuing ESS.

RESULTS

Sixty PwCF were analyzed, including 24 (40%) who elected ESS. Pursuing ESS was associated with worse SinoNasal Outcome Test (SNOT-22) total, rhinologic, psychological, and sleep dysfunction domain scores; worse Patient Health Questionnaire-9-Revised depression scores; worse Pittsburgh Sleep Quality Index total scores; worse weight, role, emotion, and eating domain scores on the Cystic Fibrosis Questionnaire-Revised; more severe disease on nasal endoscopy; and lack of modulator therapy (all p < 0.050). Multivariable regression identified that worse SNOT-22 total score was associated with electing ESS (odds ratio [OR] 1.09, 95% confidence interval [CI] 1.02-1.16, p = 0.015) and elexacaftor/tezacaftor/ivacaftor (ETI) treatment (OR 0.04, 95% CI 0.004-0.34, p = 0.004) was associated with pursing medical therapy.

CONCLUSIONS

Worse sinonasal symptom burden, lack of ETI treatment, sleep quality, depression, and nasal endoscopy scores were associated with electing ESS, while lung disease severity and sinus CT scores were not. ETI use was associated with lower odds of pursuing ESS independent of sinonasal symptom burden.

Predictive factors for decreased baseline quality of life in patients with sinonasal malignancies

BACKGROUND

The impact of sinonasal malignancies (SNMs) on quality of life (QOL) at presentation is poorly understood. The Sinonasal Outcome Test (SNOT-22) and University of Washington Quality of Life (UWQOL) are validated QOL instruments with distinctive subdomains. This study aims to identify factors impacting pretreatment QOL in SNM patients to personalize multidisciplinary management and counseling.

METHODS

Patients with previously untreated SNMs were prospectively enrolled (2015-2022) in a multicenter observational study. Baseline pretreatment QOL instruments (SNOT-22, UWQOL) were obtained along with demographics, comorbidities, histopathology/staging, tumor involvement, and symptoms. Multivariable regression models identified factors associated with reduced baseline QOL.

RESULTS

Among 204 patients, presenting baseline QOL was significantly reduced. Multivariable regression showed worse total SNOT-22 QOL in patients with skull base erosion (p = 0.02). SNOT-rhinologic QOL was worse in women (p = 0.009), patients with epistaxis (p = 0.036), and industrial exposure (p = 0.005). SNOT extranasal QOL was worse in patients with industrial exposure (p = 0.016); worse SNOT ear/facial QOL if perineural invasion (PNI) (p = 0.027). Squamous cell carcinoma pathology (p = 0.037), palate involvement (p = 0.012), and pain (p = 0.017) were associated with worse SNOT sleep QOL scores. SNOT psychological subdomain scores were significantly worse in patients with palate lesions (p = 0.022), skull base erosion (p = 0.025), and T1 staging (p = 0.023). Low QOL was more likely in the presence of PNI on UW health (p = 0.019) and orbital erosion on UW overall (p = 0.03). UW social QOL was worse if palatal involvement (p = 0.023) or PNI (p = 0.005).

CONCLUSIONS

Our findings demonstrate a negative impact on baseline QOL in patients with SNMs and suggest sex-specific and symptom-related lower QOL scores, with minimal histopathology association. Anatomical tumor involvement may be more reflective of QOL than T-staging, as orbital and skull base erosion, PNI, and palate lesions are significantly associated with reduced baseline QOL.

SNOT-22 subdomain outcomes following treatment for sinonasal malignancy: A prospective, multicenter study

BACKGROUND

Patients with sinonasal malignancy (SNM) present with significant sinonasal quality of life (QOL) impairment. Global sinonasal QOL as measured by the 22-item Sinonasal Outcomes Test (SNOT-22) has been shown to improve with treatment. This study aims to characterize SNOT-22 subdomain outcomes in SNM.

METHODS

Patients diagnosed with SNM were prospectively enrolled in a multi-center patient registry. SNOT-22 scores were collected at the time of diagnosis and through the post-treatment period for up to 5 years. Multivariable regression analysis was used to identify drivers of variation in SNOT-22 subdomains.

RESULTS

Note that 234 patients were reviewed, with a mean follow-up of 22 months (3 months-64 months). Rhinologic, psychological, and sleep subdomains significantly improved versus baseline (all p < 0.05). Subanalysis of 40 patients with follow-up at all timepoints showed statistically significant improvement in rhinologic, extra-nasal, psychological, and sleep subdomains, with minimal clinically important difference met between 2 and 5 years in sleep and psychological subdomains. Adjuvant chemoradiation was associated with worse outcomes in rhinologic (adjusted odds ratio (5.22 [1.69-8.66])), extra-nasal (2.21 [0.22-4.17]) and ear/facial (5.53 [2.10-8.91]) subdomains. Pterygopalatine fossa involvement was associated with worse outcomes in rhinologic (3.22 [0.54-5.93]) and ear/facial (2.97 [0.32-5.65]) subdomains. Positive margins (5.74 [2.17-9.29]) and surgical approach-combined versus endoscopic (3.41 [0.78-6.05])-were associated with worse psychological outcomes. Adjuvant radiation (2.28 [0.18-4.40]) was associated with worse sleep outcomes.

CONCLUSIONS

Sinonasal QOL improvements associated with treatment of SNM are driven by rhinologic, extra-nasal, psychological, and sleep subdomains.

International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors

BACKGROUND

Sinonasal neoplasms, whether benign and malignant, pose a significant challenge to clinicians and represent a model area for multidisciplinary collaboration in order to optimize patient care. The International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors (ICSNT) aims to summarize the best available evidence and presents 48 thematic and histopathology-based topics spanning the field.

METHODS

In accordance with prior International Consensus Statement on Allergy and Rhinology documents, ICSNT assigned each topic as an Evidence-Based Review with Recommendations, Evidence-Based Review, and Literature Review based on the level of evidence. An international group of multidisciplinary author teams were assembled for the topic reviews using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses format, and completed sections underwent a thorough and iterative consensus-building process. The final document underwent rigorous synthesis and review prior to publication.

RESULTS

The ICSNT document consists of four major sections: general principles, benign neoplasms and lesions, malignant neoplasms, and quality of life and surveillance. It covers 48 conceptual and/or histopathology-based topics relevant to sinonasal neoplasms and masses. Topics with a high level of evidence provided specific recommendations, while other areas summarized the current state of evidence. A final section highlights research opportunities and future directions, contributing to advancing knowledge and community intervention.

CONCLUSION

As an embodiment of the multidisciplinary and collaborative model of care in sinonasal neoplasms and masses, ICSNT was designed as a comprehensive, international, and multidisciplinary collaborative endeavor. Its primary objective is to summarize the existing evidence in the field of sinonasal neoplasms and masses.

Determining the minimal clinically important difference for the questionnaire of olfactory disorders in people with cystic fibrosis and factors associated with improvement after highly effective modulator therapy

INTRODUCTION

Olfactory dysfunction (OD) is common among people with cystic fibrosis (PwCF). The Questionnaire of Olfactory Disorders (QOD) is a validated instrument that evaluates olfactory-specific quality-of-life. The QOD minimal clinically important difference (MCID) and factors associated with olfactory improvement after elexacaftor/tezacaftor/ivacaftor have not been determined for PwCF.

METHODS

Prospective observational data were pooled from three studies that enrolled adult PwCF with chronic rhinosinusitis (CRS). QOD scores and disease characteristics were assessed. To evaluate internal consistency and calculate the QOD MCID, Cronbach's alpha and four distribution-based methods were employed. For participants who enrolled prior to elexacaftor/tezacaftor/ivacaftor, QOD scores were obtained at baseline and after elexacaftor/tezacaftor/ivacaftor initiation. Multivariable regression was used to identify factors associated with QOD improvement.

RESULTS

Of 129 PwCF included, 65 had QOD scores before and 3-6 months after starting elexacaftor/tezacaftor/ivacaftor. Mean baseline QOD score was 6.5 ± 7.9. Mean Cronbach's alpha was ≥0.85. The MCID estimates were as follows: Cohen's effect size = 1.6, standard error of measurement = 2.5, ½ baseline standard deviation = 4.0, and minimal detectable change = 6.9. Mean MCID was 3.7. Of those with pre/post elexacaftor/tezacaftor/ivacaftor QOD scores, the mean change in QOD was -1.3 ± 5.4. After elexacaftor/tezacaftor/ivacaftor, QOD improvement surpassed the MCID in 22% of participants (14/65). Worse baseline QOD scores and nasal polyps were associated with improved QOD scores after elexacaftor/tezacaftor/ivacaftor (both p < 0.04).

CONCLUSION

The QOD MCID in PwCF was estimated to be 3.7. Elexacaftor/tezacaftor/ivacaftor led to qualitative but not clinically meaningful improvements in QOD score for most PwCF; PwCF with worse baseline QOD scores and nasal polyps improved in a clinically significant manner.

Long-term quality of life after treatment in sinonasal malignancy: A prospective, multicenter study

BACKGROUND

Quality of life (QOL) for individuals with sinonasal malignancy (SNM) is significantly under-studied, yet it is critical for counseling and may impact treatment. In this study we evaluated how patient, treatment, and disease factors impact sinonasal-specific and generalized QOL using validated metrics in a large cohort over a 5-year posttreatment time frame.

METHODS

Patients with SNM who underwent definitive treatment with curative intent were enrolled in a prospective, multisite, longitudinal observational study. QOL was assessed using the 22-item Sino-Nasal Outcome Test (SNOT-22) and University of Washington Quality of Life Questionnaire (UWQOL) instruments at pretreatment baseline and multiple follow-ups through 5 years posttreatment. Multivariable modeling was used to determine demographic, disease, and treatment factors associated with disease-specific and generalized physical and social/emotional function QOL.

RESULTS

One hundred ninety-four patients with SNM were analyzed. All QOL indices were impaired at pretreatment baseline and improved after treatment. SNOT-22 scores improved 3 months and UWQOL scores improved 6 to 9 months posttreatment. Patients who underwent open compared with endoscopic tumor resection had worse generalized QOL (p < 0.001), adjusted for factors including T stage. Pterygopalatine fossa (PPF) involvement was associated with worse QOL (SNOT-22, p < 0.001; UWQOL Physical dimension, p = 0.02). Adjuvant radiation was associated with worse disease-specific QOL (p = 0.03). Neck dissection was associated with worse generalized physical function QOL (p = 0.01). Positive margins were associated with worse generalized social/emotional function QOL (p = 0.01).

CONCLUSION

Disease-specific and generalized QOL is impaired at baseline in patients with SNM and improves after treatment. Endoscopic resection is associated with better QOL. PPF involvement, adjuvant radiation, neck dissection, and positive margins were associated with worse QOL posttreatment.

Patient Outcomes following Septoplasty in Patients with Attention-deficit/Hyperactivity Disorder

Recent research has indicated that daytime manifestations of sleep-disordered breathing, frequently caused by deviated septum, can mimic many characteristic symptoms of attention-deficit/hyperactivity disorder (ADHD) and could indicate intermittent hypoxia or hypercarbia as factors in the development of ADHD. To investigate the differences in outcomes following septoplasty between patients with ADHD and deviated septum, we used a retrospective cohort design to compare outcomes in patients diagnosed with deviated septa between June 1, 2002 and June 1, 2022. We then separated these patients into four total groups based on the presence or absence of ADHD diagnosis and the presence or absence of septoplasty. After matching cohorts to create insignificant differences in age, sex, and race, we analyzed various outcomes associated with ADHD, such as conduct disorders, anxiety disorders, fractures, and substance abuse disorders. Septoplasty reduces the risk for nearly all outcomes in patients with deviated septum, with statistically significant results present in 11 of 15 outcomes in both ADHD and non-ADHD groups. The effect of septoplasty was up to 10 times greater for the ADHD cohort. Patients with ADHD who receive septoplasty display a plethora of beneficial effects, with significantly reduced risk of common sequelae such as depression, obsessive-compulsive disorder, anxiety, and addictive disorders. The difference in outcomes indicates future prospective studies into outcomes of septoplasty in patients with ADHD.

Surgical approach is associated with complication rate in sinonasal malignancy: A multicenter study

BACKGROUND

Management of sinonasal malignancy (SNM) often includes surgical resection as part of the multimodality treatment. Treatment-related surgical morbidity can occur, yet risk factors associated with complications in this population have not been sufficiently investigated.

METHODS

Adult patients with histologically confirmed SNM whose primary treatment included surgical resection were prospectively enrolled into an observational, multi-institutional cohort study from 2015 to 2020. Sociodemographic, disease, and treatment data were collected. Complications assessed included cerebrospinal fluid leak, orbital injury, intracranial injury, diplopia, meningitis, osteoradionecrosis, hospitalization for neutropenia, and subsequent chronic rhinosinusitis. The surgical approach was categorized as endoscopic resection (ER) or open/combined resection (O/CR). Associations between factors and complications were analyzed using Student's t test, Fisher's exact test, and logistic regression modeling.

RESULTS

Overall, 142 patients met the inclusion criteria. Twenty-three subjects had at least 1 complication (16.2%). On unadjusted analysis, adjuvant radiation therapy was associated with developing a complication (91.3% vs 65.5%, p = 0.013). Compared with the ER group (n = 98), the O/CR group (n = 44) had a greater percentage of higher T-stage lesions (p = 0.004) and more frequently received adjuvant radiation (84.1% vs 64.4%, p = 0.017) and chemotherapy (50.0% vs 30.6%, p = 0.038). Complication rates were similar between the ER and O/CR groups without controlling for other factors. Regression analysis that retained certain factors showed O/CR was associated with increased odds of experiencing a complication (odds ratio, 3.34; 95% confidence interval, 1.06-11.19).

CONCLUSIONS

Prospective, multicenter evaluation of SNM treatment outcomes is feasible. Undergoing O/CR was associated with increased odds of developing a complication after accounting for radiation therapy. Further studies are warranted to build upon these findings.

Clival Chordoma: Endoscopic Bilateral Transmaxillary Approach

We present a case of a large clival chordoma in a 54-year-old female with a past medical history of Turner's syndrome and a 1.5-year history of nasal congestion. The tumor was extending in the nasopharynx to both pterygopalatine fossae. An expanded endoscopic endonasal approach was selected. Stereotactic navigation was utilized. Bilateral transmaxillary approach with ethmoidectomy was performed, and a transclival corridor to the deepest portion of the tumor was created. The tumor was successfully dissected off the medial walls of the cavernous sinuses. Gross-macroscopic resection was achieved. Surgical reconstruction of the skull base comprised of a fat graft, fascia lata overlay, and dural sealant. Given the extensive nasal involvement by the tumor, a vascularized nasoseptal flap was not feasible. The patient had an unremarkable postoperative course. She underwent intensity-modulated radiation therapy (IMRT) radiotherapy 6 weeks later, and was seen in follow-up 6 months later, with no issues.

The link to the video can be found at: https://youtu.be/4bnsEUtieAw .

Development of Chronic Sphenoid Sinusitis After Sellar Reconstruction with Medpor Porous Polyethylene Implant

OBJECTIVE

The Medpor porous polyethylene implant is reported to be safe and effective for sellar reconstruction after transsphenoidal surgery (TSS). However, we have observed several cases of delayed chronic sphenoid sinusitis related to the implant. The purpose of this study is to describe the presentation and management of implant-related sphenoid sinusitis after sellar reconstruction.

METHODS

This is a retrospective study of patients who underwent endonasal TSS with Medpor sellar reconstruction between December 2008 and January 2013 at a tertiary care institution. Patient demographics, initial surgical management, sinonasal symptoms, postoperative imaging, sinusitis management, and resulting outcomes were analyzed.

RESULTS

From 2008-2013, 139 patients underwent sellar reconstruction using Medpor. Five patients (3.6%) presented between 8 and 60 months after surgery with chronic sphenoid sinusitis that required surgical management. All 5 patients presented as outpatients for management of headaches and nasal drainage, 4 patients experienced chronic nasal congestion, and 3 patients noted recurrent sinusitis. At the time of revision surgery, all 5 patients were found to have mucosal inflammation and edema surrounding the implant, and 4 of the 5 had an exposed or partially extruded implant that was removed.

CONCLUSIONS

Reconstruction of the sellar floor may be performed after TSS to prevent postoperative complications. Although porous polyethylene implants have previously been described as safe and effective for this purpose, surgeons should be aware of the risk of subsequent implant extrusion and chronic sphenoid sinusitis that can occur in a delayed manner.

Endoscopic Management of Paranasal Sinus Mucoceles: Meta-analysis of Visual Outcomes

Objective Paranasal sinus mucoceles are benign cystic lesions originating from sinus mucosa that can impinge on adjacent orbital structures, causing ophthalmic sequelae such as decreased visual acuity. Definitive treatment requires surgery. We present the first meta-analysis quantifying the effect of preoperative visual function and time to surgery on postoperative visual acuity outcomes. Data Sources PubMed, Ovid, Embase, Web of Science, and the Cochrane Library. Methods Two independent authors systematically reviewed articles describing outcomes after endoscopic sinus surgery for paranasal sinus mucoceles presenting with visual loss. Available data from case reports and series were combined to analyze the associations among preoperative visual acuity, time to surgery, and postoperative outcomes. Results Eighty-five studies were included that provided data on 207 patients. The average presenting visual acuity was 1.57 logMAR (logarithm of the minimum angle of resolution), and the average postoperative visual acuity was 0.21 logMAR, with visual improvement in 71.5% of cases. Preoperative visual acuity ≥1.52 logMAR correlated with postoperative improvement >1 logMAR ( R = 0.4887, P < .0001). A correlation was found between a time to surgery <6 days and postoperative improvement ( R = 0.297, P < .0001). Receiver operator curve analysis of these thresholds demonstrated a moderately accurate prognostic ability (area under the curve: 75.1 for preoperative visual acuity and 73.1 for time to surgery). Conclusion Visual loss resulting from paranasal sinus mucoceles is potentially reversible in most cases, even those presenting with poor vision. When possible, surgery should be performed promptly after diagnosis, but emergency surgery does not appear to be necessary for vision restoration.

Landmarks for rapid localization of the sphenopalatine foramen: A radiographic morphometric analysis

Background:

Transnasal endoscopic sphenopalatine artery ligation is becoming the procedure of choice for surgical management of intractable posterior epistaxis. Landmarks for localization of the sphenopalatine foramen can assist in rapid surgical exposure of the sphenopalatine artery.

Objective:

This study examined distances from easily identified endoscopic surgical landmarks to the sphenopalatine foramen.

Methods:

By using computed tomography of the sinus to study radiologic anatomy in 50 adults, distances were measured between five simple endoscopic landmarks and the sphenopalatine foramen. The two-tailed t-test was used for statistical analysis.

Results:

Right- and left-sided measurements were similar. The mean (standard deviation [SD]) anteroposterior distances to the sphenopalatine foramen were the following: from the maxillary line (36.7 ± 5.5 mm), anterior head of the middle turbinate (33.8 ± 6.7 mm), basal lamella (11.8 ± 1.9 mm), and choanal arch (−9.2 ± 1.4 mm). The mean (SD) distance in the vertical dimension from the nasal floor was 26.6 ± 2.6 mm. Female patients had statistically shorter distances to the sphenopalatine foramen from the maxillary line, anterior head of the middle turbinate, choanal arch, and nasal floor.

Conclusion:

Reliable endoscopic landmarks exist in relation to consistent anatomic structures and can be used to help quickly estimate the location of the sphenopalatine foramen at the onset of the procedure.

Clinical Examination of Tissue Eosinophilia in Patients with Chronic Rhinosinusitis and Nasal Polyposis

OBJECTIVE

(1) Describe clinical and histopathologic findings in patients with chronic rhinosinusitis with nasal polyps (CRSwNP). (2) Determine if tissue and serum eosinophilia predicts disease severity in CRSwNP.

STUDY DESIGN

Case series with chart review.

SETTING

Academic hospital specializing in respiratory and allergic disease.

SUBJECTS

Patients with CRSwNP treated from 2008 to 2010.

METHODS

Clinical data were collected; sinus computed tomography (CT) scans were scored according to the Lund-Mackay system; and surgical specimens were evaluated for degree of tissue eosinophilia. Statistical analysis was performed to compare eosinophilia with indicators of disease severity.

RESULTS

Seventy CRSwNP patients were included, with a mean Lund-Mackay score of 16.7; 62.1% of patients had severe asthma, and 62.9% were aspirin sensitive. Elevated tissue eosinophil level did not correlate with medication usage, olfactory symptoms, or Lund-Mackay scores, nor did it correlate with presence of asthma or aspirin-sensitivity (P = .09). Patients with mild asthma had significantly more tissue eosinophils versus patients with severe asthma, possibly because of the high amount of chronic corticosteroid use in severe asthmatics. There was no correlation between tissue and serum eosinophil counts (P = .97), but there was a significant positive correlation between CT score and peripheral eosinophil level (P < .05).

CONCLUSIONS

Higher serum eosinophil levels may indicate more extensive mucosal disease as measured on CT scan. Neither serum nor tissue eosinophilia predicted disease severity in our retrospective analysis of CRSwNP patients, and serum eosinophil level did not serve as a marker of tissue eosinophilia.

Systematic Review of the Effectiveness of Perioperative Prophylactic Antibiotics for Skull Base Surgeries

Background

Perioperative antibiotics are commonly used in endoscopic skull base surgeries as prophylaxis for infectious complications, e.g., meningitis. The role of perioperative prophylactic antibiotics in endoscopic sinus surgery is unclear, and the routine use of prophylactic antibiotics in endoscopic skull base surgery is also highly debated. Currently, there is no formal recommendation for perioperative antibiotic use in skull base surgery, and regimens vary greatly from one institution to the next.

Objective

To assess perioperative antibiotics as prophylaxis against infectious complications in patients who underwent endoscopic skull base surgery.

Data Sources

PubMed, Ovid EMBASE, and the Cochrane Library.

Methods

A systematic review that examined perioperative antibiotic use in endoscopic skull base and craniofacial surgeries was conducted. Inclusion criteria were prospective or retrospective study design and clinical trials related to the use of antibiotics within 30 days of skull base surgery. End points included infectious complications such as (1) meningitis and (2) sinusitis.

Results

A total of 2543 articles were identified by the initial search, and 5 articles met inclusion criteria. The five eligible trials were all observational and involved different types of skull base surgical procedures and antibiotic regimens.

Conclusions

Despite institutional variability in antibiotic regimens, meningitis rarely occurs after skull base procedures and seems to be encountered most frequently in open craniofacial surgeries. A systematic review revealed a limited number of published studies, all observational in study design, which precluded a formal meta-analysis. A novel large-scale randomized-controlled clinical trial is needed to evaluate antibiotic selection and need in endoscopic skull base surgery.

Complications following primary and revision transsphenoidal surgeries for pituitary tumors

OBJECTIVES/HYPOTHESIS

This study aimed to determine the incidence of major complications following both primary and revision transsphenoidal pituitary surgery. Major complications included endocrinopathic, skull base, orbital, hemorrhagic and thromboembolic complications, respiratory failure, and death. Secondarily, this study aimed to examine factors associated with the occurrence of complications.

STUDY DESIGN

Retrospective cohort analysis of California and Florida all-payer databases from 2005 to 2008.

METHODS

The major complication rate following both primary and revision transsphenoidal pituitary surgery was calculated. Bivariate analyses were performed to investigate the relationship of patient characteristics with complication occurrence, and a multivariate model was constructed to determine risk factors associated with these complications.

RESULTS

There were 5,277 primary cases and 192 revision cases that met inclusion criteria. There was a nonsignificant absolute difference of 3.09% (95% confidence interval [CI]: -11.00 to 16.14) between the rate of complications following primary (n = 443, 8.39%) and revision (n = 22, 11.46%) surgeries. Multivariate analyses showed that patients with Medicare (odds ratio [OR]:1.74, 95% CI: 1.17 to 2.61), Medicaid (OR: 2.13, 95% CI: 1.59 to 2.86), or a malignant neoplasm (OR: 3.10, 95% CI: 1.62 to 5.93) were more likely to have complications.

CONCLUSIONS

The rate of major complications following transsphenoidal pituitary surgery is lower than earlier retrospective reports. The overall complication rate following revision surgery was not significantly different from primary surgery. Insurance status and a diagnosis of a malignant neoplasm were associated with a higher rate of complications.

LEVEL OF EVIDENCE

2C.

Combined high-field intraoperative magnetic resonance imaging and endoscopy increase extent of resection and progression-free survival for pituitary adenomas

PURPOSE

The clinical benefit of combined intraoperative magnetic resonance imaging (iMRI) and endoscopy for transsphenoidal pituitary adenoma resection has not been completely characterized. This study assessed the impact of microscopy, endoscopy, and/or iMRI on progression-free survival, extent of resection status (gross-, near-, and sub-total resection), and operative complications.

METHODS

Retrospective analyses were performed on 446 transsphenoidal pituitary adenoma surgeries at a single institution between 1998 and 2012. Multivariate analyses were used to control for baseline characteristics, differences during extent of resection status, and progression-free survival analysis.

RESULTS

Additional surgery was performed after iMRI in 56/156 cases (35.9%), which led to increased extent of resection status in 15/156 cases (9.6%). Multivariate ordinal logistic regression revealed no increase in extent of resection status following iMRI or endoscopy alone; however, combining these modalities increased extent of resection status (odds ratio 2.05, 95% CI 1.21-3.46) compared to conventional transsphenoidal microsurgery. Multivariate Cox regression revealed that reduced extent of resection status shortened progression-free survival for near- versus gross-total resection [hazard ratio (HR) 2.87, 95% CI 1.24-6.65] and sub- versus near-total resection (HR 2.10; 95% CI 1.00-4.40). Complication comparisons between microscopy, endoscopy, and iMRI revealed increased perioperative deaths for endoscopy versus microscopy (4/209 and 0/237, respectively), but this difference was non-significant considering multiple post hoc comparisons (Fisher exact, p = 0.24).

CONCLUSIONS

Combined use of endoscopy and iMRI increased pituitary adenoma extent of resection status compared to conventional transsphenoidal microsurgery, and increased extent of resection status was associated with longer progression-free survival. Treatment modality combination did not significantly impact complication rate.

Comparison of radiographic and clinical characteristics of low-risk and high-risk cystic fibrosis genotypes

BACKGROUND

Patients with cystic fibrosis (CF) exhibit a wide range of disease severity, and can be broadly stratified into high-risk and low-risk groups based on cystic fibrosis transmembrane conductance regulator (CFTR) mutation class. Patients with a low-risk genotype are often diagnosed as adults, with milder disease and lower sweat chloride values. The aim of the current study was to better understand radiographic and clinical characteristics of sinus disease in adult CF patients within this risk category.

METHODS

Adult CF patients were retrospectively compared to a control group of patients with chronic rhinosinusitis. CF diagnostic testing and pulmonary characteristics were compared between high-risk and low-risk CF groups, and sinus CT findings were compared among all 3 groups.

RESULTS

When comparing CF cohorts (n = 25 and 30, respectively), earlier age at diagnosis (p < 0.001), higher sweat chloride values (p < 0.001), lower forced expiratory volume in 1 second (FEV1 ) values (p < 0.001), and a higher prevalence of pulmonary infection with Pseudomonas aeruginosa (p = 0.001) were found in the high-risk genotype group. A significantly increased incidence of sinus hypoplasia/aplasia and bony sclerosis was seen when comparing both CF groups to the control cohort (n = 30), as well as when comparing the high-risk and low-risk CF genotype cohorts.

CONCLUSION

The current study describes clinicopathologic findings of sinus disease in adult CF patients in the context of genotype severity. Our data demonstrate that while patients within a low-risk genotype cohort have generally milder lung disease, they retain classic radiographic findings of CF sinus disease that can help raise the index of suspicion for undiagnosed CF.

Complications of primary and revision functional endoscopic sinus surgery for chronic rhinosinusitis

OBJECTIVES/HYPOTHESIS

The goal of this study was to determine the incidence of major complications following primary and revision functional endoscopic sinus surgery (FESS). In addition, this study aimed to determine factors associated with the occurrence of complications including patient and provider characteristics and the use of image guidance system (IGS) technology.

STUDY DESIGN

Retrospective cohort analysis of California and Florida all-payer databases from 2005 to 2008.

METHODS

The rates of major surgical complications (skull base, orbital, and hemorrhagic) after primary and revision FESS were calculated, and bivariate analyses were performed to investigate relationships of complications with demographic and clinical characteristics. A multivariate model was used to determine risk factors for the occurrence of major complications.

RESULTS

Among 78,944 primary FESS cases, 288 major complications were identified representing a complication rate of 0.36% (95% CI 0.32%-0.40%). The major complication rate following revision cases (n = 19; 0.46%) and primary cases (n = 288; 0.36%) was similar (OR = 1.26; 95% CI 0.79-2.00). Multivariate analysis showed that patients who were >40 years old, had a primary payer of Medicaid, had surgery involving the frontal sinus, or had image guidance during surgery were at higher risk for major complications.

CONCLUSION

The rate of major complications (0.36%) associated with primary FESS is lower than earlier reports. The rate of major complications following revision FESS (0.46%) was found to be similar to primary cases. IGS, insurance status, age, and extent of surgery were found to be associated with an increased risk of major complications following FESS.

LEVEL OF EVIDENCE

2C.

Basal lamella relaxing incision improves endoscopic middle meatal access

BACKGROUND

Lateralization of the middle turbinate is a commonly cited factor leading to failure of functional endoscopic sinus surgery (FESS). Inadequate medialization during FESS may require repeat intraoperative attempts, and may lead to destabilization and mucosal trauma. A novel technique is described that increases middle meatal area and provides more definitive medialization at the outset of FESS.

METHODS

Twenty-nine middle turbinate medializations were prospectively evaluated in 18 consecutive patients undergoing primary ESS. Three intraoperative images of the middle meatus were obtained in the native position, after Freer medialization, and after basal lamella relaxing incision (BLRI). Measurements of middle meatal area were then calculated in a blinded and randomized fashion.

RESULTS

Distances measured from the middle turbinate to the lateral nasal wall for each position ranged from 0 to 8 mm (median = 3.00 mm) for the native position, 0.5 to 10 mm (median = 5.00 mm) for standard Freer medialization, and 3 to 21 mm (median = 10.00 mm) for BLRI. Friedman's analysis of variance (ANOVA) showed that there was significant difference between the 3 measurements, and the post hoc Wilcoxon signed ranks tests showed that BLRI distance (median = 10; 95% confidence interval [CI], 7-11.2) was significantly larger than both standard Freer (median = 5; 95% CI, 4-6.2) and native (median = 3; 95% CI, 2-3) and that standard Freer was significantly larger than native (all p values <0.001).

CONCLUSION

BLRI is a safe, controlled technique that provides significantly greater medialization of the middle turbinate compared to standard medialization techniques. BLRI significantly enhances the operative space within the middle meatus.

Complications in FESS: Doing Right When Things Go Wrong

Program Description: Functional Endoscopic Sinus Surgery (FESS) is one of the most frequently performed procedures in otorhinolaryngology and is thus responsible for a significant incidence of complications. Thorough knowledge of the paranasal sinuses and their surrounding structures and adequate surgical experience are keys to preventing surgical complications. Special considerations in hemostasis help optimize visualization and increase safety. Meticulous preoperative review of the patient’s imaging studies is critical in successfully identifying the patient’s unique anatomic and surgical issues, thereby facilitating avoidance of complications. Maxillofacial CT is an absolute requirement prior to surgery, and systematic review of danger areas is critical. These will be reviewed and discussed in detail. Despite these preparatory measures, both minor and major complications may still occur. The surgeon must therefore possess the skill set to deal with these complications in order to consider him- or herself a safe surgeon. Specific complications including cerebrospinal fluid leak, neurovascular injuries, and orbital complications will be discussed in a case presentation format. Algorithms on how to address such scenarios will be presented. Finally, the medicolegal aspects of surgical complications will be considered including documentation and discussion with the patient and their families.

Educational Objectives: 1) Learn strategies to avoid complications during FESS. 2) Understand management (both surgical and medicolegal) of FESS-related complications.

Endoscopic surgical management of vidian nerve schwannoma

Vidian nerve schwannomas are highly unusual, with only two reported cases in the world literature, and present with a constellation of symptoms that may be extremely vague. In the reported cases, open techniques have been utilized that required significant dismantling of the midfacial skeleton to access and manage these skull base lesions. Over the last 15 years, a paradigm shift in base of skull surgery has evolved with the advent of transnasal endoscopic techniques and instrumentation, improved surgical access and resectability of most skull-based pathologies, including vidian nerve lesions as reported here. We describe the varied clinical presentation and radiologic findings in two patients with such rare lesions. In addition, in one of these patients, we report on the first use of an expanded endonasal technique to access and remove vidian nerve schwannomas entirely endoscopically.

Intracapsular vs. extracapsular tonsillectomy: a comparison of pain

OBJECTIVE

To measure differences in postoperative pain in children undergoing intracapsular tonsillectomy vs. extracapsular tonsillectomy.

STUDY DESIGN

Prospective clinical trial carried out at a tertiary children's hospital over 1 year.

METHODS

The study included 43 patients age 5 to 19 years with adenotonsillar hypertrophy, 27 undergoing extracapsular tonsillectomy and 16 undergoing intracapsular tonsillectomy. Tonsillectomy was performed in either an intracapsular or extracapsular fashion using bipolar electrosurgical scissors and monopolar suction cautery for hemostasis. Residents under faculty supervision performed all operations. Postoperative pain was assessed using the Wong-Baker Faces Pain Scale through postoperative day 10. The patients recorded in a standardized diary pain scores and analgesic use. The main outcome measure was postoperative pain as measured by the Wong-Baker Faces Pain Scale. The quantity of postoperative pain medicine consumed was a secondary outcome measure.

RESULTS

Average postoperative pain for extracapsular tonsillectomy was 5.21 on a 10-point scale versus 2.75 for intracapsular tonsillectomy (P < .0001).

CONCLUSIONS

Intracapsular tonsillectomy with bipolar scissors results in less postoperative pain than extracapsular tonsillectomy with bipolar scissors in children age 5 to 19 years.

Thyrohyoid Approach to Cidofovir Injection: A Case Study

Various techniques for injection into the larynx have been well described, including transoral injection with indirect laryngoscopy or direct laryngoscopy and transcutaneous injection through the thyroid cartilage or cricothyroid membrane. We describe a case not amenable to these techniques, in which entry through the thyrohyoid membrane for injection of cidofovir was successfully performed with a thyrohyoid approach. This technique is described, and comparisons are made with currently available techniques.