Endoscopic endonasal approach for olfactory groove meningioma resection: Strategies and outcomes in a retrospective case series

OBJECTIVE

Though the endoscopic endonasal approach (EEA) is a widely accepted treatment for skull base tumors, the specific use of EEA for olfactory groove meningiomas (OGMs) is debated, with variable outcomes reported in the literature. We review the surgical results of OGM resections for one surgeon including the operative approach, surgical nuances, and outcomes, with a focus on factors relating to patient selection which favor EEA over transcranial approaches.

METHODS

We retrospectively reviewed thirteen cases of endoscopic endonasal resection of olfactory groove meningiomas. Patient characteristics, clinical characteristics, surgical outcomes, and complications were analyzed. Extent of resection was determined based on volumetric analysis of pre- and postoperative MRI.

RESULTS

Anatomic characteristics that render a tumor difficult to access fully are lateral extension beyond the mid-orbit and anterior extension to the falx. Simpson Grade I resection was achieved in 11/13 (84.6 %) cases. Mean pre-operative tumor volume was 8.99 cm3 (range 2.19-16.79 cm3), and 92 % of tumors were WHO grade I. We demonstrate 2 cases of smell preservation, possible with small unilateral tumors and tumors that are confined to either the anterior or posterior portion of the cribriform plate. The post-operative CSF leak rate was 7.7 %, without prophylactic lumbar CSF drainage. The mortality rate was 7.7 % (n = 1) after infectious complications following CSF leak.

CONCLUSIONS

Endoscopic endonasal resection of olfactory groove meningiomas is an effective and safe operative method with outcomes and complication rates comparable to transcranial approaches. Key considerations include careful patient selection and familiarity with technical nuances of endoscopic endonasal approach for this specific tumor type.

Adverse events associated with budesonide nasal irrigation reported to the US Food and Drug Administration: 2007 to 2022

KEYPOINTS

Between 2007 and 2022, the FDA received 119 US-based reports mentioning budesonide nasal irrigation. Most reports were submitted by patients and alerted FDA to off-label usage of budesonide. Notable adverse events reported to the FDA included headache, dyspnea, and blurred vision.

The Impact of Gender on Long-Term Quality of Life After Sinus Surgery for Chronic Rhinosinusitis

OBJECTIVE

To identify the impact of gender on the clinical outcomes of endoscopic sinus surgery (ESS) through the comparison of quality of life measures in female and male patients who undergo surgical treatment for chronic rhinosinusitis (CRS).

STUDY DESIGN

Prospective observational cohort study.

METHODS

Patients with CRS completed the 22-item Sino-Nasal Outcome Test (SNOT-22) and EuroQol 5-Dimension Survey (EQ-5D) preoperatively and annually for 5 years following ESS. Health utility values (HUV) were calculated from EQ-5D scores. Comparisons of cohort characteristics were performed with chi-square and t-tests. A multivariable linear mixed effects model evaluated changes in SNOT-22 and HUV over time by gender.

RESULTS

Among the 1268 patients (54% female) enrolled, 789 and 343 completed postoperative surveys at one and 5 years, respectively. Preoperatively, females experienced more severe symptoms: mean SNOT-22 score (51.1 ± 20.9 female vs. 44.7 ± 20.0 male, p < 0.001) and HUV (0.80 ± 0.14 female vs. 0.84 ± 0.11 male, p < 0.001). These gender differences were resolved by year one postoperatively (SNOT-22: p = 0.083; HUV: p = 0.465). Two years after surgery, however, females reported more severe symptoms (SNOT-22: 25.6 ± 20.7 female vs. 21.5 ± 17.4 male, p = 0.005; HUV: 0.88 ± 0.12 female vs. 0.90 ± 0.11 male, p = 0.018), a difference that persisted at year five. These gender-related differences remained after adjusting for age, race, ethnicity, nasal polyps, history of prior ESS, and smoking status (p < 0.001). Within-subject improvement was comparable between genders (SNOT-22: p = 0.869; HUV: p = 0.611).

CONCLUSION

Females with CRS reported more severe symptoms both before and 5 years after surgery compared to their male counterparts. Understanding the mechanism behind these gender-related differences is important for optimizing CRS treatment.

LEVEL OF EVIDENCE

2 Laryngoscope, 133:3319-3326, 2023.

Trends in price, spending, and utilization of omalizumab among Medicare beneficiaries

KEY POINTS

Between January 2005 and January 2023, the average selling price of omalizumab increased by nearly 60%. Between 2016 and 2021, Medicare Part B and D spending on omalizumab totaled over $3.7 billion. Between 2016 and 2021, Medicare Part B and D utilization of omalizumab increased by approximately 30%.

Physician Turnover Among Otolaryngologists in the United States, 2014-2021

Using publicly available Medicare data, we performed a retrospective cross-sectional analysis of separation between otolaryngologists and affiliated medical groups between 2014 and 2021. During this period, the cumulative turnover rate among otolaryngologists was 36.4%, with annual turnover rates ranging between 6.2%-10.2%. Otolaryngologist turnover rates varied by career stage and group size.

Indications for Absorbable Steroid-Eluting Sinus Implants: Viewpoint via the Delphi Method

Absorbable steroid-eluting sinus implants provide targeted corticosteroid release over a sustained period and are designed to prevent both undesirable adhesion formation and sinus ostia restenosis. Here, we highlight the key evidence of these implants to date and query a group of experts via a Delphi process on the indications and optimal timing for intraoperative or in-office placement of these implants. Six of a total of 12 statements reached consensus and were accepted. Overall, experts largely agree that intraoperative or in-office use of steroid-eluting stents could be considered for patients: (1) who are diabetic or intolerant of oral steroids, (2) undergoing extended frontal sinus surgery, and (3) with recurrent stenosis. Given the lack of expert consensus on other key statements, clinicians should carefully consider these treatment options on a case-by-case basis after shared decision-making.

Defining the Health Utility Value of Medical Management of Chronic Rhinosinusitis: A Prospective Pilot Study

The extent to which medical management of chronic rhinosinusitis (CRS) may improve health utility value (HUV) remains unknown. We conducted a prospective pilot study to longitudinally assess HUV via the EQ-5D-5L questionnaire in patients with CRS who were receiving medical therapy but did not undergo sinus surgery. The primary study outcome was HUV at 12-month follow-up; secondary end points included HUV at baseline and 3- and 24-month follow-up. Our study enrolled 115 patients who received the following medical treatments: saline irrigations (n = 83, 72.2%), steroid sprays (n = 93, 80.9%), antihistamines (n = 64, 55.7%), steroid irrigations (n = 29, 25.2%), and oral antibiotics (n = 58, 50.4%). There was a statistically significant improvement (mean, +0.073; P = .003) in HUV at 12 months (minimum clinically important difference, 0.055) as compared with baseline. However, there was no statistically significant trend in HUV over time between baseline and 24-month follow-up (P = .3033). These findings can inform cost-effectiveness research as new medical therapies for CRS emerge.

Private Payer-Negotiated Prices for Outpatient Otolaryngologic Surgery

In January 2021, the Centers for Medicare & Medicaid Services began requiring hospitals to publish price transparency files listing all prices negotiated with payers. We performed a cross-sectional analysis of payer-negotiated prices for commonly performed outpatient otolaryngology surgery at all hospitals scored by the US News & World Report in otolaryngology. We compared prices among hospitals (across-center ratios) and among payers at the same hospital (within-center ratios). Price disclosure rates were low overall for otolaryngologic surgery (maximum, 26.7% for bronchoscopy). Across-center ratios ranged from 3.5 (adjacent tissue transfer/rearrangement <10 cm²; raw median price range, $1384-$7047) to 18.6 (cochlear implant placement; raw median price range, $2417-$60,255). Median within-center ratios ranged between 2.7 (intraoperative navigation) and 5.4 (total thyroidectomy). Although price variation may signal opportunities for cost savings, patients may have limited ability to comparison shop due to hospital nondisclosure. Further investigation is necessary to examine the factors affecting price variation for otolaryngologic procedures.

Educational utility of an online video-based teaching tool for sinus and skull base surgery

OBJECTIVE

Surgical education has undergone major changes in recent years, as hands-on learning opportunities have been replaced or supplemented with online tools. The goal of this project is to examine the educational impact of a surgical training website, SinusVideos.com, on otolaryngologists at various levels of training.

METHODS

Visitors to the website were asked to complete a survey after viewing a narrated video of a surgical procedure. Surveys were analyzed for demographics, needs assessment, and educational impact.

RESULTS

A total of 105 completed surveys were completed by 68 (64.8%) attendings/practicing physicians, 32 residents/fellows (30.5%), and 5 medical students (4.8%). Whereas 14.3% of viewers reported online videos as their primary source for surgical preparation, 70.5% considered them important secondary supplements. After viewing a video, 92.4% of respondents reported a gained confidence in performing the surgery, and 62.9% said the video altered how they would perform the surgery in the future. Viewers' ratings of their knowledge (on a 1-7 Likert scale) of a particular surgical procedure before vs after watching the observed procedure increased significantly for participants at all levels of training-medical students (2.8 before vs 5.4 after, P < .01), residents/fellows (4.8 before vs 5.8 after, P < .0001), and attendings/practicing physicians (5.6 before vs 6.4 after, P < .0001).

CONCLUSION

High quality online surgical videos appear to be an effective learning tool for surgical trainees and practicing physicians alike. The educational benefit of such tools, as well as their widespread accessibility, makes them a powerful instrument for the training of surgeons worldwide.

LEVEL OF EVIDENCE

Level 5.

A Clinical Decision Analysis for Use of Antibiotic Prophylaxis for Nonabsorbable Nasal Packing

OBJECTIVE

Nonabsorbable nasal packing is often placed for the treatment of epistaxis or after sinonasal or skull base surgery. Antibiotics are often prescribed to prevent toxic shock syndrome (TSS), a rare, potentially fatal occurrence. However, the risk of TSS must be balanced against the major risk of antibiotic use, specifically Clostridium difficile colitis (CDC). The purpose of this study is to evaluate in terms of cost-effectiveness whether antibiotics should be prescribed when nasal packing is placed.

STUDY DESIGN

A clinical decision analysis was performed using a Markov model to evaluate whether antibiotics should be given.

SETTING

Patients with nonabsorbable nasal packing placed.

METHODS

Utility scores, probabilities, and costs were obtained from the literature. We assess the cost-effectiveness of antibiotic use when the risk of community-acquired CDC is balanced against the risk of TSS from nasal packing. Sensitivity analysis was performed for assumptions used in the model.

RESULTS

The incremental cost-effectiveness ratio for antibiotic use was 334,493 US dollars (USD)/quality-adjusted life year (QALY). Probabilistic sensitivity analysis showed that not prescribing antibiotics was cost-effective in 98.0% of iterations at a willingness to pay of 50,000 USD/QALY. Sensitivity analysis showed that when the risk of CDC from antibiotics was greater than 910/100,000 or when the incidence of TSS after nasal packing was less than 49/100,000 cases, the decision to withhold antibiotics was cost-effective.

CONCLUSIONS

Routine antibiotic prophylaxis in the setting of nasal packing is not cost-effective and should be reconsidered. Even if antibiotics are assumed to prevent TSS, the risk of complications from antibiotic use is of greater consequence.

LEVEL OF EVIDENCE

3a.

Infection After Endoscopic Dacryocystorhinostomy: Incidence and Implications

BACKGROUND

Endoscopic dacryocystorhinostomy (EN-DCR) is an increasingly common procedure performed by otolaryngologists. While EN-DCR has a high rate of success at relieving blockage of the lacrimal system, little is known regarding associated postoperative infection (POI) rates and risk factors.

OBJECTIVE

The purpose of this study was to identify factors associated with the occurrence of postoperative orbital and rhinologic infection in a large cohort of patients undergoing EN-DCR.

METHODS

A retrospective review of 582 patients who underwent EN-DCR was performed. All patients received antibiotic prophylaxis as a single intraoperative intravenous administration and a ten-day postoperative oral course. Clinical and demographic information was reviewed, including the occurrence of acute orbital or rhinologic infection within 30 days of surgery. Multivariable analysis was performed to identify risk factors associated with POI.

RESULTS

Fifteen of 582 patients (2.6%) developed POI following EN-DCR. The most common POI was acute rhinosinusitis (10/15, 66.7%), followed by acute dacryocystitis (2/15, 13.3%), preseptal cellulitis (2/15,13.3%), and acute bacterial conjunctivitis (1/15, 6.7%). The majority of patients (464/582, 79.7%) underwent concurrent endoscopic sinus surgery (ESS). In most cases (302/464, 65.1%), ESS was performed to address comorbid rhinosinusitis, whereas 7.8% (36/464) of patients underwent surgery to enhance surgical access to the lacrimal sac. Patients who underwent concurrent ESS were less likely to develop POI (OR: 0.17, CI: 0.04-0.80, p < 0.05). Evidence of mucopurulence at surgery increased the likelihood of POI (OR: 6.24, CI: 1.51-25.84, p < 0.05).

CONCLUSION

Mucopurulence at the time of surgery significantly increased the risk of POI, whereas concurrent ESS, performed most commonly to address comorbid rhinosinusitis, significantly decreased the risk of POI. Awareness of risk factors for POI and appropriate surgical management of concurrent rhinosinusitis can lead to reduced infectious complications after EN-DCR.

Endoscopic Transoral Image-Guided Retrieval of Infratemporal Fossa Foreign Bodies

Removal of foreign bodies from the infratemporal fossa is surgically challenging and fraught with risks. This report describes our experience with a minimally invasive transoral technique, utilizing endoscopic and image guidance technology, for retrieval of infratemporal fossa foreign bodies in 6 patients. The technique was successfully applied in all cases with identification and retrieval of the foreign bodies, which included 4 hypodermic needles broken off during dental injections, a cottonoid surgical sponge lost during a facial fracture repair, and a maxillary molar displaced during attempted extraction. Complications were limited to transient postoperative lingual and inferior alveolar nerve sensory deficits in 1 patient.

Suction mitigation of airborne particulate generated during sinonasal drilling and cautery

Background

Coronavirus disease 2019 (COVID‐19) has significantly impacted endonasal surgery, and recent experimentation has demonstrated that sinonasal drilling and cautery have significant propensity for airborne particulate generation immediately adjacent to the surgical field. In the present investigation, we assessed nasopharyngeal suctioning as a mitigation strategy to decrease particulate spread during simulated endonasal surgical activity.

Methods

Airborne particulate generation in the 1‐µm to 10‐µm range was quantified with an optical particle sizer in real‐time during cadaveric‐simulated anterior and posterior endonasal drilling and cautery conditions. To test suction mitigation, experiments were performed both with and without a rigid suction placed in the contralateral nostril, terminating in the nasopharynx.

Results

Both anterior (medial maxillary wall and nasal septum) and posterior (sphenoid rostrum) drilling produced significant particulate generation in the 1‐µm to 10‐µm range throughout the duration of drilling (p < 0.001) without the use of suction, whereas nasopharyngeal suction use eliminated the detection of generated airborne particulate. A similar effect was seen with nasal cautery, with significant particle generation (p < 0.001) that was reduced to undetectable levels with the use of nasopharyngeal suction.

Conclusion

The use of nasopharyngeal suctioning via the contralateral nostril minimizes airborne particulate spread during simulated sinonasal drilling and cautery. In the era of COVID‐19, this technique offers an immediately available measure that may increase surgical safety.

Airborne Aerosol Generation During Endonasal Procedures in the Era of COVID-19: Risks and Recommendations

OBJECTIVE

In the era of SARS-CoV-2, the risk of infectious airborne aerosol generation during otolaryngologic procedures has been an area of increasing concern. The objective of this investigation was to quantify airborne aerosol production under clinical and surgical conditions and examine efficacy of mask mitigation strategies.

STUDY DESIGN

Prospective quantification of airborne aerosol generation during surgical and clinical simulation.

SETTING

Cadaver laboratory and clinical examination room.

SUBJECTS AND METHODS

Airborne aerosol quantification with an optical particle sizer was performed in real time during cadaveric simulated endoscopic surgical conditions, including hand instrumentation, microdebrider use, high-speed drilling, and cautery. Aerosol sampling was additionally performed in simulated clinical and diagnostic settings. All clinical and surgical procedures were evaluated for propensity for significant airborne aerosol generation.

RESULTS

Hand instrumentation and microdebridement did not produce detectable airborne aerosols in the range of 1 to 10 μm. Suction drilling at 12,000 rpm, high-speed drilling (4-mm diamond or cutting burs) at 70,000 rpm, and transnasal cautery generated significant airborne aerosols (P < .001). In clinical simulations, nasal endoscopy (P < .05), speech (P < .01), and sneezing (P < .01) generated 1- to 10-μm airborne aerosols. Significant aerosol escape was seen even with utilization of a standard surgical mask (P < .05). Intact and VENT-modified (valved endoscopy of the nose and throat) N95 respirator use prevented significant airborne aerosol spread.

CONCLUSION

Transnasal drill and cautery use is associated with significant airborne particulate matter production in the range of 1 to 10 μm under surgical conditions. During simulated clinical activity, airborne aerosol generation was seen during nasal endoscopy, speech, and sneezing. Intact or VENT-modified N95 respirators mitigated airborne aerosol transmission, while standard surgical masks did not.

Cost Utility Analysis of Dupilumab Versus Endoscopic Sinus Surgery for Chronic Rhinosinusitis With Nasal Polyps

OBJECTIVE

Both endoscopic sinus surgery (ESS) and biologic therapies have shown effectiveness for medically-refractory chronic rhinosinusitis with nasal polyps (CRSwNP) without severe asthma. The objective was to evaluate cost-effectiveness of dupilumab versus ESS for patients with CRSwNP.

STUDY DESIGN

Cohort-style Markov decision-tree economic model with a 36-year time horizon.

METHODS

A cohort of 197 CRSwNP patients who underwent ESS were compared with a matched cohort of 293 CRSwNP patients from the SINUS-24 and SINUS-52 Phase 3 studies who underwent treatment with dupilumab 300 mg every 2 weeks. Utility scores were calculated from the SNOT-22 instrument in both cohorts. Decision-tree analysis and a 10-state Markov model utilized published event probabilities and primary data to calculate long-term costs and utility. The primary outcome measure was incremental cost per quality-adjusted life year (QALY), which is expressed as an Incremental Cost Effectiveness Ratio. One-way and probabilistic sensitivity analyses were performed.

RESULTS

The ESS strategy cost $50,436.99 and produced 9.80 QALYs. The dupilumab treatment strategy cost $536,420.22 and produced 8.95 QALYs. Because dupilumab treatment was more costly and less effective than the ESS strategy, it is dominated by ESS in the base case. One-way sensitivity analyses showed ESS to be cost-effective versus dupilumab regardless of the frequency of revision surgery and at any yearly cost of dupilumab above $855.

CONCLUSIONS

The ESS treatment strategy is more cost effective than dupilumab for upfront treatment of CRSwNP. More studies are needed to isolate potential phenotypes or endotypes that will benefit most from dupilumab in a cost-effective manner.

LEVEL OF EVIDENCE

2C Laryngoscope, 131:E26-E33, 2021.

National Geographical Variation in Sinus Balloon Dilation

OBJECTIVE

The primary aim of this study was to describe national variations in sinus balloon dilation (SBD), examine the relationship between endoscopic sinus surgery (ESS) and SBD prevalence patterns, and evaluate associations between reimbursement rates and regional variations in sinus surgery.

STUDY DESIGN

Retrospective observational study.

SETTING

Medicare Provider Utilization and Payment (PUP) Part B Data from January 1, 2016, to December 31, 2016.

SUBJECTS AND METHODS

Physicians in the PUP Part B Database Performing ESS or SBD in 2016. States were stratified into average- or high-volume utilizers based on the number of ESS procedures and SBD procedures per population and compared.

RESULTS

Eight states were classified as high-volume utilizers of SBD-Florida, Kansas, Louisiana, Mississippi, Nevada, New Mexico, South Dakota, and Texas. Only 3 of these states-Kansas, Mississippi, and Nevada-were classified as high-volume utilizers of ESS. Reimbursement rates were significantly higher for SBD as compared to ESS ($1538 [interquartile range (IQR), 1473-1664] vs $335 [IQR, 261-412] per procedure, P < .001). High-volume utilizer SBD states had a higher number of otolaryngologists (13.0 [IQR, 7-16] vs 6.0 [IQR, 2-3]) otolaryngologists per state (P < .001) and a trend toward an increased rate of performing ESS procedures (19 [IQR, 19-41] vs 6.0 [IQR, 2-32], P = .034) procedures per million residents) than average-volume utilizer SBD states.

CONCLUSIONS

The southern United States has a significantly higher rate of SBD procedures performed compared to the rest of the country, but these rates do not appear to be directly related to statewide variations in SBD reimbursement.

Periostin and Inflammatory Disease: Implications for Chronic Rhinosinusitis

OBJECTIVE

To provide a comprehensive overview of the emerging role of periostin, an extracellular matrix protein, as a key component in the development, diagnosis, and treatment of patients with chronic rhinosinusitis.

DATA SOURCES

Medline database.

REVIEW METHODS

A state of the art review was performed targeting English-language studies investigating the role of periostin in cardiopulmonary, neoplastic, and inflammatory diseases, with emphasis on recent advances in the study of periostin in chronic rhinosinusitis.

CONCLUSIONS

Periostin has emerged as a novel biomarker and therapeutic target for numerous human pathologies, including cardiac, pulmonary, and neoplastic disease. The upregulation of periostin in chronic rhinosinusitis suggests the potential for similar roles among patients with sinonasal disease.

IMPLICATIONS FOR PRACTICE

Chronic rhinosinusitis is a widespread disease with major clinical and societal impact. A critical limitation in the current treatment of patients with chronic rhinosinusitis is the absence of clinically relevant biomarkers to guide diagnosis and treatment selection. A review of the literature supports a likely role of periostin as a biomarker of chronic rhinosinusitis, as well as a novel therapeutic target in the future treatment of patients with sinonasal disease.

Does bilateral inferior turbinate reduction affect long-term quality-of-life outcomes in patients undergoing endoscopic sinus surgery?

BACKGROUND

The objective of this study was to evaluate the impact of bilateral inferior turbinate reduction (BITR) on patient-reported quality of life (QOL) following endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS).

METHODS

This was a prospective cohort study. Patients with CRS, who were recruited from 10 different otolaryngologic practices between 2011 and 2014, completed the 22-item Sino-Nasal Outcome Test (SNOT-22), Chronic Sinusitis Survey (CSS), and EuroQol 5 Dimension (EQ-5D) survey at baseline, and at 12, 24, 36, and 48 months after ESS. A total of 113 patients who underwent ESS with BITR were compared to 788 patients who underwent ESS without BITR.

RESULTS

Significant demographic and comorbid differences between BITR and non-BITR cohorts included age (41 vs 49 years, p < 0.0001), presence of asthma (19% vs 36%, p < 0.0001), prior sinus surgery (22% vs 53%, p < 0.0001), and concurrent septoplasty (80% vs 53%, p < 0.0001), respectively. On univariate analysis, patients who underwent ESS with or without BITR were found to have statistically significant improvement in disease-specific (SNOT-22 and CSS) and general (EQ-5D) QOL scores at years 1 through 4 (p < 0.05). On multivariate regression, however, the performance of BITR was not associated with any improvements in these outcome measures.

CONCLUSION

Patients undergoing ESS achieve similar long-term improvement in both disease-specific and general QOL regardless of the performance of concurrent BITR.

The role of industry influence in sinus balloon dilation: Trends over time

OBJECTIVE

Balloon dilation (BD) is a controversial alternative to conventional sinus surgery. The role of industry on practice patterns remains unknown. The aim of this study was to determine whether industry payments from BD manufacturers influence practice patterns for otolaryngologists and evaluate how these payments change over time.

METHODS

Retrospective cohort study using Medicare Provider Utilization and Payment (PUP) Data and Center for Medicare and Medicaid Services Open Payments (OP) general payment datasets. A total of 294 otolaryngologists identified in the PUP dataset who performed BD procedures from January 1, 2013, to December 31, 2015, were cross-referenced in the OP dataset from January 1, 2014, to December 31, 2016, for BD manufacturer payments. Payments to surgeons performing BD stratified by amount, type, and number of procedures performed were primary outcome measures.

RESULTS

Of the 294 otolaryngologists reporting BD procedures, 223 (76%) received payments from a company that manufactures BD devices. Receipt of $2,500 in BD payments was associated with performance of one additional BD procedure, and consulting fees were most positively associated with performing additional BD procedures (P = 0.006). The providers receiving the most in BD payments were more likely to continue to receive the most in payments, regardless of number of BD procedures performed. Performing more BD procedures did not correlate with decrease in other sinus procedures.

CONCLUSION

Payments to otolaryngologists from manufacturers of sinus BD devices are associated with the performance of an increased number of such procedures. Surgeons should consider the impact of interactions with industry when evaluating patients for BD procedures.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:1540-1545, 2018.

The impact of asthma on the cost effectiveness of surgery for chronic rhinosinusitis with nasal polyps

BACKGROUND

The objective of this work was to evaluate the impact of asthma on the cost-effectiveness profile of endoscopic sinus surgery (ESS) compared to medical therapy for patients with chronic rhinosinusitis with nasal polyps (CRSwNP).

METHODS

The study design consisted of a cohort-style Markov decision-tree cost utility analysis with a 35-year time horizon. Matched cohorts of CRSwNP patients with (n = 95) and without (n = 95) asthma who underwent ESS were compared with cohorts of patients from the national Medical Expenditures Survey Panel (MEPS) database who underwent medical management for chronic rhinosinusitis (CRS). Baseline, 1-year, and 2-year health utility values were calculated from responses to the EuroQol-5 Dimension (EQ-5D) instrument in both cohorts. The primary outcome measure was the incremental cost effectiveness ratio (ICER) for each cohort.

RESULTS

The reference cases for CRSwNP patients with and without asthma yielded ICERs for ESS vs medical therapy alone of $12,066 per quality-adjusted life year (QALY) and $7,369 per QALY, respectively. At a willingness-to-pay threshold of $50,000/QALY, the ICER scatter plots demonstrated 86% and 99% certainty that the ESS strategy was the most cost-effective option for CRSwNP patients with and without asthma, respectively. ESS was not significantly more cost effective for CRSwNP patients without asthma (p = 0.494).

CONCLUSION

ESS remains cost effective compared to medical therapy for patients both with and without asthma. While the comorbidity of asthma results in an inferior ICER result, it does not result in a statistically significant negative impact on the overall cost effectiveness of ESS.

The value of frontal sinusotomy for chronic rhinosinusitis with nasal polyps-A cost utility analysis

OBJECTIVES/HYPOTHESIS

The number of surgical procedures performed for frontal sinusitis and the associated costs have increased dramatically over the past decade. The purpose of this study was to evaluate the cost-effectiveness of endoscopic frontal sinusotomy (EFS) in patients with chronic rhinosinusitis with nasal polyposis (CRSwNP).

STUDY DESIGN

Cohort-style Markov decision-tree economic model with a 36-year time horizon.

METHODS

Matched cohorts of CRSwNP patients who underwent endoscopic sinus surgery (ESS) with (n = 139) and without (n = 49) EFS were compared to each other and to patients (n = 139) from the Medical Expenditures Survey Panel database who underwent medical management for chronic rhinosinusitis. Multi-year health utility values were calculated from responses to the EuroQol 5-Dimension instrument. The primary outcome measure was the incremental cost-effectiveness ratio (ICER).

RESULTS

Decision analysis showed that ESS without EFS proved more cost-effective than ESS with EFS or medical management. ESS without EFS compared to medical management yielded an ICER of $9,004/quality-adjusted life year (QALY). ESS with EFS compared to ESS without EFS yielded an ICER of $62,310/QALY. At a willingness-to-pay (WTP) threshold of $50,000/QALY, ESS without EFS was more cost-effective than ESS with EFS with 52.1% certainty. These results were robust to one-way analysis and probabilistic sensitivity analysis.

CONCLUSIONS

ESS remains a cost-effective intervention compared to medical therapy alone for patients with CRSwNP. In this study, the addition of frontal sinusotomy during ESS for patients with CRSwNP was not found to be cost-effective at a WTP threshold of $50,000/QALY, but may be cost effective at a higher threshold of $100,000/QALY.

LEVEL OF EVIDENCE

2c. Laryngoscope, 128:43-51, 2018.

Does the Timing of Middle Turbinate Resection Influence Quality-of-Life Outcomes for Patients with Chronic Rhinosinusitis?

Objective

To evaluate the impact of bilateral middle turbinate resection (BMTR) on patient-reported quality of life following primary and revision endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS).

Study Design

Prospective cohort study.

Setting

Tertiary care center.

Subjects and Methods

Patients with CRS who were recruited from 11 otolaryngologic practices completed the Sino-Nasal Outcome Test–22, Chronic Sinusitis Survey, and EuroQol 5-Dimension questionnaires at baseline, as well as 3 and 12 months after ESS. In the primary ESS cohort (n = 406), patients who underwent BMTR (n = 78) at the time of surgery were compared with patients (n = 328) whose middle turbinates were preserved. In the revision ESS cohort (n = 363), a similar comparison was made between patients who did (n = 64) and did not (n = 299) undergo BMTR.

Results

Sino-Nasal Outcome Test–22, Chronic Sinusitis Survey, and EuroQol 5-Dimension scores showed similar improvements for both the turbinate resection and preservation cohorts at 3 months ( P < .001) and 12 months ( P < .001) after surgery. For patients who underwent revision surgery, the performance of BMTR resulted in greater improvement in Chronic Sinusitis Survey scores at 1 year as compared with the turbinate preservation group (change from baseline: 28.1 vs 20.7, respectively; P = .026). History of tobacco use and the presence of nasal polyps did not affect clinical outcomes at any time point.

Conclusion

Patients who underwent BMTR during primary and revision sinus surgery reported similar benefits in quality-of-life outcomes 1 year after surgery. In select patients undergoing revision sinus surgery, the performance of BMTR results in improved disease-specific quality of life.

Anosmia: Differential diagnosis, evaluation, and management

The ability to scrutinize our surroundings remains heavily dependent on the sense of smell. From the ability to detect dangerous situations such as fires to the recollection of a fond memory triggered by an odor, the advantages of an intact olfactory system cannot be overstated. Outcomes studies have highlighted the profound negative impact of anosmia and parosmia on the overall quality of life. The National Institute on Deafness and Other Communication Disorders estimates that ∼1.4% of the United States population experiences chronic olfactory dysfunction and smell loss. Efforts have focused on improving both the diagnosis of olfactory dysfunction through olfactory testing and improved reporting of treatment outcomes of olfactory training. The purpose of this article was to review the differential diagnosis, workup, and current treatment strategies of anosmia and smell disorders.

The Role of Chemotherapy in the Management of Sinonasal and Ventral Skull Base Malignancies

In most cases of advanced sinonasal and ventral skull base cancer, a multimodal treatment approach provides the best chance for improved outcomes. Depending on the tumor type and extent of disease, systemic chemotherapy has been shown to play an important role in neoadjuvant, concomitant, and adjuvant settings. The lack of randomized trials continues to limit its indications. Further high-quality studies are needed to understand ideal chemotherapeutic regimens and their role and sequential timing in sinonasal and ventral skull base cancer.

Cost utility analysis of endoscopic sinus surgery for chronic rhinosinusitis with and without nasal polyposis

OBJECTIVE

To evaluate the cost-effectiveness of endoscopic sinus surgery (ESS) compared to medical therapy for patients with chronic rhinosinusitis (CRS) with and without nasal polyposis (NP).

STUDY DESIGN

Cohort-style Markov decision-tree economic model with a 36-year time horizon.

METHODS

Two cohorts of 229 CRS patients with and without NP who underwent ESS were compared with a matched cohort of 229 CRS patients from the Medical Expenditures Survey Panel database (Agency for Healthcare Research and Quality, Rockville, MD) who underwent medical management. Utility scores were calculated from sequential patient responses to the EuroQol five-dimensions questionnaire. Decision-tree analysis and a 10-state Markov model utilized published event probabilities and primary data to calculate long-term costs and utility. The primary outcome was the incremental cost per quality-adjusted life year (QALY). Thorough sensitivity analyses were performed.

RESULTS

The reference case for CRS with NP yielded an incremental cost-effectiveness ratio (ICER) for ESS versus medical therapy of $5,687.41/QALY. The reference case for CRS without NP yielded an ICER of $5,405.44/QALY. The cost-effectiveness acceptability curve in both cases demonstrated 95% certainty that the ESS strategy was the most cost-effective option at a willingness-to-pay threshold of $20,000/QALY or higher. These results were robust to one-way and probabilistic sensitivity analysis.

CONCLUSION

This study demonstrates the cost-effectiveness of ESS compared to medical therapy alone for the management of CRS patients both with and without NP. The presence of nasal polyps was not found to affect the overall cost-effectiveness of ESS.

LEVEL OF EVIDENCE

2C. Laryngoscope, 127:29-37, 2017.

Skull base erosion and associated complications in sphenoid sinus fungal balls

BACKGROUND

Sphenoid sinus fungal balls (SSFB) are rare entities that can result in serious orbital and intracranial complications. There are few published reports of complications that result from SSFB.

OBJECTIVE

To review the incidence of skull base erosion and orbital or intracranial complications in patients who present with SSFB.

METHODS

A retrospective review was performed of all the patients with SSFB who were treated at the Massachusetts Eye and Ear Infirmary from 2006 to 2014. Presenting clinical data, radiology, operative reports, pathology, and postoperative course were reviewed.

RESULTS

Forty-three patients with SSFB were identified. Demographic data were compared between patients with (39.5%) and those without (61.5%) skull base erosion. Two patients underwent emergent surgery for acute complications of SSFB (one patient with blindness, one patient who had a seizure). Both patients with acute complications had evidence of skull base erosion, whereas no patients with an intact skull base developed an orbital or intracranial complication (p = 0.15). All the patients were surgically managed via an endoscopic approach.

CONCLUSION

SSFBs are rare but may cause significant skull base erosion and potentially severe orbital and intracranial complications if not treated appropriately. Endoscopic sphenoidotomy is effective in treating SSFB and should be performed emergently in patients who presented with associated complications.

The Effect of Initial Tracheoesophageal Voice Prosthesis Size on Postoperative Complications and Voice Outcomes

OBJECTIVES

The optimal initial size of tracheoesophageal voice prosthesis (TEVP) for tracheoesophageal voice restoration (TEVR) remains unclear. As purported advantages exist favoring the placement of both 16F and 20F prostheses, this study compares complications and voicing outcomes after placement of 16 and 20 French (F) prostheses.

METHODS

All cases of TEVR at an academic medical center were retrospectively reviewed (2007-2013). Complications including dislodgement, leakage, infection, and granulation tissue were compared. Outcomes including frequency of prosthesis change, acquisition of speech, and time to fluent speech were compared.

RESULTS

Of 47 patients, 25 received 20F prostheses, and 22 received 16F. Postoperative complications were similar between groups, including leakage around the prosthesis (P = .373) and aspiration pneumonia (P = .670). There were no significant differences in timing of voicing or ability to achieve fluency. Although the 20F group appeared to undergo fewer prostheses changes per year (3.0 vs 5.3) and had a longer duration of use before first prosthesis change (76 vs 43 days), neither difference was found to be statistically significant.

CONCLUSION

Voice restoration was successfully achieved using either 16F or 20F prostheses. Prosthesis diameter did not significantly affect complications or voicing. Both prostheses may be placed with safety and efficacy, allowing the practitioner to choose based on the potential individual benefits of either device.

Pituitary incidentalomas

INTRODUCTION

Incidentally discovered pituitary adenomas are more and more commonly encountered in endocrinology and neurosurgical practices. Often they present as difficult problems in management strategies. This review summarizes the latest evidence and opinions in a variety of settings in which incidental pituitary tumors are discovered, including subclinical pituitary tumor apoplexy.

METHODS

A systematic literature review was accomplished using a spectrum of contemporary sources for information regarding pituitary incidentalomas.

RESULTS

Up to date findings regarding epidemiology, definition of pituitary incidentaloma, patient evaluation, diagnostic studies, and management are presented.

CONCLUSIONS

Current experience from a multidisciplinary pituitary center is presented, with indications for treatment and longitudinal care of these challenging patients.

The natural history and clinical characteristics of paranasal sinus mucoceles: a clinical review

BACKGROUND

A retrospective data analysis at a university tertiary referral center was conducted to characterize the natural history, clinical characteristics, management principles, and outcomes of paranasal sinus mucoceles.

METHODS

A chart review was performed on 102 patients with a total of 133 paranasal sinus mucoceles who were treated between 1987 and 2011 at the Hospital of the University of Pennsylvania.

RESULTS

The study population included patients with a mean age of 53.1 years (range, 22-82 years). Patients were diagnosed with a mucocele on average 5.3 years following prior functional endoscopic sinus surgery (FESS), 17.7 years following prior paranasal sinus trauma, and 18.1 years following prior open sinus surgery. The most common presenting symptoms were headache (42.1%) and maxillofacial pressure (28.6%). The most common sites were the frontal, frontoethmoidal, and ethmoid sinuses. Fifty-seven mucoceles (44.9%) had intraorbital extension, intracranial extension, or both. Out of 133 mucoceles, 114 underwent ESS without complication.

CONCLUSION

The length of time between prior surgery or trauma and mucocele presentation highlights the importance of long-term follow-up in both patient care and in the understanding and reporting of surgical outcomes. In this study, most patients exhibited nonspecific symptomatology despite extensive mucoceles and a significant incidence of orbital and skull-base erosion. The endoscopic approach can be safely used for the management of such lesions.

Genome-wide comparison of paired fresh frozen and formalin-fixed paraffin-embedded gliomas by custom BAC and oligonucleotide array comparative genomic hybridization: facilitating analysis of archival gliomas

Array comparative genomic hybridization (aCGH) is a powerful tool for detecting DNA copy number alterations (CNA). Because diffuse malignant gliomas are often sampled by small biopsies, formalin-fixed paraffin-embedded (FFPE) blocks are often the only tissue available for genetic analysis; FFPE tissues are also needed to study the intratumoral heterogeneity that characterizes these neoplasms. In this paper, we present a combination of evaluations and technical advances that provide strong support for the ready use of oligonucleotide aCGH on FFPE diffuse gliomas. We first compared aCGH using bacterial artificial chromosome (BAC) arrays in 45 paired frozen and FFPE gliomas, and demonstrate a high concordance rate between FFPE and frozen DNA in an individual clone-level analysis of sensitivity and specificity, assuring that under certain array conditions, frozen and FFPE DNA can perform nearly identically. However, because oligonucleotide arrays offer advantages to BAC arrays in genomic coverage and practical availability, we next developed a method of labeling DNA from FFPE tissue that allows efficient hybridization to oligonucleotide arrays. To demonstrate utility in FFPE tissues, we applied this approach to biphasic anaplastic oligoastrocytomas and demonstrate CNA differences between DNA obtained from the two components. Therefore, BAC and oligonucleotide aCGH can be sensitive and specific tools for detecting CNAs in FFPE DNA, and novel labeling techniques enable the routine use of oligonucleotide arrays for FFPE DNA. In combination, these advances should facilitate genome-wide analysis of rare, small and/or histologically heterogeneous gliomas from FFPE tissues.