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Objectives: An increasing proportion of patients who are candidates for endoscopic sinus surgery can be treated as an outpatient. A preoperative risk assessment is needed to evaluate eligibility for day surgery. This study analyses the effectiveness of a risk assessment scoring system which examines medical, procedure-related, and socioeconomic factors. Design: Prospective multicenter study. Setting: Three center study including Klinik Hirslanden, Zurich, Switzerland, Luzerner Kantonsspital, Lucerne, Switzerland and HNO-Klinik München-Bogenhausen, Munich, Germany. Participants: Patients with endoscopic sinus procedures between January 1st, 2017 and December 31st, 2018. Main outcome measures: The "day surgery risk score" consisted of three subgroups with medical, procedure-related and socioeconomic risk factors were assessed to determine if these predicted the severity of postoperative complications. Results: Three-hundred and one patients who underwent endoscopic sinus surgery were included. The score resulted in a median value of 5 [5, 5]. In the Receiver-Operating Curve (ROC—the true-positive rate against the false-positive rate), the Area Under the Curve (AUC) was 0.59 with 95% confidence interval from 0.49 to 0.69, indicating that the "day surgery risk score" may be no better at predicting the likelihood of a complication than a random classification model. Conclusions: The "day surgery risk score" is a straightforward risk assessment which combines medical, procedure-related, and socioeconomic factors. The score is easy to use but in trying to decide whether a patient is eligible for ambulatory endoscopic sinus surgery it did not predict whether a complication was more likely to occur. [ABSTRACT FROM AUTHOR]

In the original publication [ABSTRACT FROM AUTHOR]

Purpose: Most cases of non-traumatic nasal cerebrospinal fluid (CSF) leaks occur spontaneously without any obvious reason. Severe and life-threatening complications are possible consequences. Endoscopic repair is considered the gold standard; however, diagnosis and therapy of these CSF leaks stay challenging.Methods: In this retrospective analysis, patients who presented with spontaneous nasal CSF leaks from 2006 to 2017 were included. Symptoms, diagnostics, localization of the skull base defect, surgical method, outcome, and postoperative treatment were recorded.Results: Twenty four patients were included. 8 patients presented with symptoms of meningitis. The skull base defects were most commonly located in the anterior ethmoid roof—especially in the cribriform plate—and in the lateral part of the sphenoid sinus. 21 patients had a BMI above 25. In only 13 cases the defect could be detected preoperatively via computed tomography or additional magnetic resonance imaging. In all patients intraoperative visualization of the CSF leak was possible using intrathecal application of sodium-fluorescein. Endoscopic repair was the initial surgical method for all patients and proved to be successful in 80% of the cases. In most cases surgical revision was performed endoscopically; however, in two patients an open transpterygoidal approach was necessary.Conclusions: Spontaneous nasal CSF leaks often initially present with symptomatic meningitis. Imaging does not always clearly identify the skull base defect. Common localizations are the anterior ethmoid roof and the lateral sphenoid sinus. Obesity seems to be a predisposing factor. In most cases, endoscopic repair with low morbidity is possible; however, an individualized approach is necessary. [ABSTRACT FROM AUTHOR]

Introduction: Dissection courses are important for trainees and surgeons in mastering the skills required to perform endoscopic sinus surgery (ESS) which is a common surgery in otorhinolaryngology. Aim: To evaluate the benefits of ESS training courses and ways to improve training. Material and methods: In a prospective study using a structured questionnaire, participants of ESS courses in the United Kingdom, Malaysia, India and Thailand were asked on their experiences in these courses and suggestions on improving them. Results and discussion: The majority of the participants have experiences in performing ESS prior to joining the course. Infundibulotomy was considered the easiest dissection step in ESS while frontal sinus surgery was considered the most challenging by the majority of the participants. The motivation for most of the participants in joining the course is to improve their skills with almost all stating that their expectations of the course have been fulfilled with improvement of their surgical techniques, anatomical skills and on patient's safety. Almost all the participants were satisfied with the course and would recommend attending it. Conclusions: ESS dissection courses are an integral part in the learning process of trainees in becoming a competent surgeon and for surgeons to improve their techniques. Continuous improvement should be made to ensure that the participants will benefit from attending the course. [ABSTRACT FROM AUTHOR]

Purpose: The current standard endoscopic technique is a high resolution visualisation up to Full HD and even 4 K. A recent development are 3D endoscopes providing a 3-dimensional picture, which supposedly gives additional information of depth, anatomical details and orientation in the surgical field. Since the 3D-endoscopic technique is new, little scientific evidence is known whether the new technique provides advantages for the surgeon compared to the 2D-endoscopic standard technique in FESS. This study compares the standard 2D-endoscopic surgical technique with the new commercially available 3D-endoscopic technique. Methods: The prospective randomized interventional multicenter study included a total of 80 referred patients with chronic rhinosinusitis with and without polyps without prior surgery. A bilateral FESS procedure was performed, one side with the 2D-endoscopic technique, the other side with the 3D-endoscopic technique. The time of duration was measured. Additionally, a questionnaire containing 20 items was completed by 4 different surgeons judging subjective impression of visualisation and handling. Results: 2D imaging was superior to 3D apart from "recognition of details", "depth perception" and "3D effect". For usability properties 2D was superior to 3D apart from "weight of endoscopes". Mean duration for surgery was 26.1 min for 2D and 27.4 min. for 3D without statistical significance (P = 0.219). Conclusion: Three-dimensional endoscopy features improved depth perception and recognition of anatomic details but worse overall picture quality. It is useful for teaching purposes, yet 2D techniques provide a better outcome in terms of feasibility for routine endoscopic approaches. [ABSTRACT FROM AUTHOR]

Background: The endonasal access to the frontal recess and sinus may be complicated by a variety of anatomical variations. Previous classifications of these variants were characterized by proper names or position information without anatomical reference. The IFAC is intended to simplify the classification of anatomical variations of the frontoethmoidal complex. The aim of this study was to analyse a representative number of sinus CT scans to assess the incidence of anatomical variations according to the IFAC and to compare the results with previous classifications. In addition, the coincidence of complex anatomical variations and radiological sings of opacification was investigated. Methodology/principal: Two hundred and forty-nine sinus CT scans were analysed in multiplanar reconstructions. Exclusion criteria were previous operations on the paranasal sinuses, malignant diseases, and an insufficient image quality. All anatomical variants were analysed according to the IFAC criteria. In addition, the coincidence of radiological sings of opacification and the presence of anatomical variations of the frontal recess and sinus were investigated. Results: The analysis revealed Agger nasi cells in 95% of the CT scans. Supra agger cells (SACs) were detected in 49% and Supra agger frontal cells (SAFCs) in 25% of the data sets. Suprabulla cells (SBCs) were detected in 89% and Supra bulla frontal cells (SBFCs) in 27% of the scans. Supraorbital ethmoid cells (SECs) were detectable in 9% and interfrontal septal cells in 28% of the scans. Despite a partially strong narrowing of the frontal recess, no increased occurrence of radiological sings of opacification could be detected (p > 0.05). Conclusions: Anatomical variations in the frontoethmoidal area are very common. According to the IFAC criteria, in 43% of the patients, cells could be detected with pneumatization to or into the frontal sinus. The IFAC is structured more clearly compared to previous classifications due to the anatomical aspect. It represents the most consistent classification regarding surgical planning. Further studies will demonstrate the scientific and clinical value of this classification. [ABSTRACT FROM AUTHOR]

In otorhinolaryngology, dermatology and reconstructive surgery biomaterials as implants and a variety of lasers are used. Laser light applied near to an implant could have the risk to damage these materials. Therefore, their resistance exposed to laser light is of interest. A diode laser emitting at 940 nm and a CO laser were used to investigate its effects to the biomaterials Bioverit®, Medpor® and Palacos®, and in addition, an excised implant containing Medpor® and nasal turbinate tissue, excised and fixed in formalin. The macro- and microscopic changes of the material, temperature development during laser energy application in dependency to distance of fibre and material, time of exposure and applied power were investigated. Interaction of diode laser light with Bioverit® (0 mm distance, 360 s, 10 W, 3,600 J) resulted in minimal microscopic effects in direct contact of with the fibre. Using Medpor® (1 mm, 10s, 10 W, 100 J) resulted in melting and perforation. In the case of Palacos® (0.6 mm, 10s, 10 W, 100 J), melting occurred creating a flat excavation. The effect to Medpor® in nasal turbinate (1-2 mm, 10s, 10 W, 100 J) showed tissue denaturation and carbonisation and creation of a hole. The interaction of the CO laser with Bioverit® (3 cm, 0.5, 1 and 5 s, 2, 10 or 20 W) induced melting and discolouring resulting finally in a perforating hole. Depending on the material, first damage starts 10 s after an impact of 100 J (threshold value). So interaction between laser energy and biomaterials occurs. This should be carefully considered during clinical laser treatments especially nearby implants. [ABSTRACT FROM AUTHOR]

Abstract: Primary paragangliomas of the paranasal sinuses are very rare conditions with only few cases described in the literature. Paragangliomas are locally aggressive, often recur and can metastasize. Usually, open surgery is used to resect such tumors from the sinonasal tract. Here, a case of a large paraganglioma of the left maxillary sinus and nasal cavity, which was successfully removed using the Onyx® embolic agent two days prior to minimally invasive image guided endoscopic sinus surgery, is reported. This case demonstrates that large vascular tumors of the sinonasal tract can be successfully managed by endoscopic endonasal sinus surgery. The patient has no evidence of recurrence after 12 months of follow-up. [Copyright &y& Elsevier]

Recalcitrant forms of recurrent nasal polyposis are problematic for patients as for rhinosurgeons. In aspirin-sensitive patients, aspirin desensitization is supposed to prevent recurrence by targeting the metabolism of arachidonic acid. Aspirin-sensitive patients ( n = 65) following aspirin desensitization after functional endoscopic sinus surgery (FESS) for recurrent nasal polyposis under daily intake of 500-mg aspirin were compared to a post-FESS group ( n = 81) of aspirin-sensitive individuals using exclusively topical mometasone. Quality of life (QoL) scores including sinonasal, pulmonal and general QoL items as well as endoscopic endonasal examination findings were evaluated during the postoperative follow-up period. After a follow-up period of minimum 18 months, a significant improvement in nasal obstruction, rhinorrhea, post nasal drip, sense of smell, facial pain, sleep quality and further general QoL items in desensitized patients was found compared to aspirin-sensitive controls. Improvement in sinonasal symptoms was evident, whereas the severity of asthmatic symptoms showed no significant changes. Although the pathophysiology of aspirin sensitivity is still not fully understood and the therapy is not sufficiently investigated, aspirin desensitization seems to have a positive effect on QoL scores concerning sinonasal symptoms and should be regarded as a possible postoperative treatment modality for recurrent nasal polyposis in aspirin-sensitive individuals. [ABSTRACT FROM AUTHOR]

Objectives. Hemangiopericytoma is a rare tumor entity deriving from pericytes. Less than 5% of hemangiopericytoma occur in the nasal cavity and are characterised by a rather benign nature with low tendency of metastasis. However, as the recurrence rate in the literature ranges from 9.5% to 50%--depending on the length of followup--a radical surgical resection is considered as the goldstandard treatment. Only a few years ago, a wide external approach, usually via lateral rhinotomy or Caldwell-Luc, was performed. Endoscopic techniques were regarded as appropriate for small low-vascularised tumors only. Methods. We present the case of a 64-year-old patient with an extended sinonasal hemangiopericytoma, who was successfully treated by an endoscopic controlled endonasal tumor resection after embolisation with Onyx. Further, to support the new treatment option, we review the literature concerning all features of sinonasal hemangiopericytomas and their therapeutical management. Results/Conclusion. Onyx, which has not been described in the context of hemangiopericytoma yet, is a very effective embolic agent for a preoperative embolisation of sinonasal hemangiopericytoma allowing a safe endoscopic surgery. [ABSTRACT FROM AUTHOR]

Paranasal fungus ball can cause chronic rhinosinusitis. Removal via functional endoscopic sinus surgery is usually performed; however objective data on the overall benefit and patient satisfaction are very scarce. The study focuses on the clinical outcome and the quality of life following endoscopic surgery due to fungus ball sinusitis. Forty patients diagnosed with fungus ball sinusitis who underwent functional endoscopic surgery were included. Epidemiologic data, pre-, intra- and postoperative findings were recorded. Surgical success, the detailed benefit and the health-related quality of life were objectively assessed 1 year after the surgery based on a standardized questionnaire (modified SNOT 20) and the Glasgow Benefit Inventory. Health-related quality of life improved significantly in >90% of patients ( p < 0.05). There were no serious complications or recurrences. As the treatment of choice functional endoscopic sinus surgery of paranasal fungus ball sinusitis is associated with exceptionally high patient satisfaction. [ABSTRACT FROM AUTHOR]

The ossifying fibroma is a fibro-osseous lesion that rarely occurs in the paranasal sinuses. Due to its tendency to behave locally aggressively, complete resection is generally recommended. A subdivision into the aggressive juvenile ossifying fibroma (JOF) and the less aggressive cemento-ossifying fibroma of the adult (COF) is clinically reasonable. The objective of the study was to retrospectively analyze the management and follow-up of the patients diagnosed with ossifying fibroma at our ENT-department from 2006 to 2010. A total of five patients were included, thereby comprising one of the largest case series of paranasal ossifying fibromas. In three patients an exclusively endoscopically controlled resection was performed. Two patients with asymptomatic COF declined surgery. Within the 2-year follow-up, no progression was detected. While the JOF should always be surgically treated, for the asymptomatic paranasal ossifying fibroma of the adult (COF) a wait-and-scan strategy, similar to that recommended for osteomas or fibrous dysplasia, could be an option in selected cases. [ABSTRACT FROM AUTHOR]

Osteomas are among the most common benign tumors of the paranasal sinuses. Symptomatic osteomas are most often found in the frontal recess and the frontal sinus. While the extranasal approach is still a part of the treatment concept for removing osteomas at this localization, over the last years the endoscopically controlled endonasal approach has greatly gained in importance due to the improved surgical equipment. We retrospectively analyzed the surgical indication, surgical approach and outcome of the removal of osteomas of the frontal recess and the frontal sinus performed at our hospital between 1996 and 2010. The exact surgical technique, intra- and postoperative complications, the duration of the hospital stay and the follow-up and subjective contentment of the patients were evaluated. With a total of 24 patients being included, the study comprises one of the largest groups of patients with osteomas of the frontal recess and sinus. Over the study period, the frequency of the endoscopic approach clearly increased. Previously suggested guidelines for the endoscopic resection of a frontal sinus osteoma turned out to be superseded. Endoscopically controlled resection even of large, adversely located osteomas of the frontal recess and the frontal sinus is becoming increasingly possible, but is still naturally limited by the individual anatomic conditions and the need for experienced surgeons. [ABSTRACT FROM AUTHOR]

The aim of this study is to evaluate the haemostatic effect of carboxy-methylated cellulose (CMC) nasal packing following functional endoscopic sinus surgery (FESS). The design includes an investigator-initiated, randomized, single-blinded, controlled, prospective clinical study. A bilateral FESS procedure was performed on 41 patients. At the end of the operation, one side was randomly filled with CMC nasal packing, the other side remained without packing. The patients were blinded to the side of nasal packing and were postoperatively examined on the 1st day, after 2 and 4 weeks and the extent of the postoperative bleeding was quantified with a clinical grading system. Even though there were slightly more postoperative bleedings reported for the non-packed sides as compared to the CMC-packed sides, these differences were at no point statistically significant within the monitored postoperative period of 4 weeks. In the examined collective, the CMC packing investigated did not statistically prove to have an effect on bleeding control in this study design. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Functional endoscopic sinus surgery (FESS) is not frequently performed in children. The aim of our retrospective analysis was to determine symptoms, surgical extent, complications and outcome of operated children. Methods: For a period from 1994 to 2004 the clinical records of the Department of Otorhinolaryngology, LMU Munich, Germany, were screened for pediatric FESS procedures. Subsequently, a retrospective chart review was performed in all cases. For assessment of outcome, symptom- and quality of life-related questionnaires were sent out to all patients. Results: 115 children had a FESS procedure due to CRS, 77 were boys and 38 girls. The response rate of the questionnaires was 64% (73 of 115); the mean follow up of these was 5.4 (±1.8) years. 76% of the patients reported an improvement of their chief symptoms and 71% of their general quality of life. The overall quality of life had improved significantly (p <0.01) on VAS. In CRS patients nasal obstruction was completely relieved in 62.3%, facial pain in 65.5% and postnasal drip in 72.5%. Improvement of primary nasal symptoms (PNS) of CRS in patients with CF, asthma or allergies as well as in youngsters who had started or continued to smoke 35 out of 73 (48%) was significantly less. Conclusions: Self-assessment after FESS showed in 76% improvement of chief symptoms in children with CRS. Besides known negative prognostic factors for long-term outcome as CF, asthma, nasal polyps, allergies and previous surgery, smoking was correlated with less favourable improvement. [Copyright &y& Elsevier]

Abstract: Introduction: Early diagnosis of cancer of the upper aerodigestive tract (UADT) and its precursors may greatly improve the prognosis of the patients concerned. It seems possible that this goal can be reached using a combination of non-invasive optical methods. Materials and methods: In groups of patients (n=15–80) with, or at a high risk of developing, a malignant lesion of the UADT, different optical methods were investigated: autofluorescence imaging (AFI; n=80) and enhanced fluorescence imaging (EFI; n=79) using 5-aminolevulinic acid (5-ALA)-induced protoporphyrin IX (PpIX) as tools for optical screening; multiple fluorophore analysis (MFA; n=18) and elastic scattering spectroscopy (ESS; n=25) as “optical biopsy” methods; and optical coherence tomography (OCT; n=15) as a method to investigate the depth of a lesion (i.e. to differentiate dysplasia from early invasive cancer). Results: Using AFI or EFI in combination with conventional inspection, the detection of dysplastic/early malignant lesions was markedly improved (6 additional lesions for AFI vs. 7 for EFI). The lesions were furthermore easier to delimit from innocuous mucosa when applying fluorescence imaging. Both “optical biopsy” methods (MFA and ESS) proved able to differentiate between normal and cancerous mucosa (MFA: sensitivity 100%/specificity 94.4%; ESS: sensitivity 70.0%/specificity 78.8%). Using OCT, it was possible to clearly identify epithelial layers, basal membranes and superior lamina propria and disruptions within these in all patients examined. Conclusions: Even though so far the results are based on a very limited number of patients, the optical diagnostic methods investigated appear to be helpful for the detection, differentiation and mapping of early mucosal lesions of the UADT. Especially when used in combination with one another, they show great promise for improving early tumor diagnosis to the point that invasive measures such as diagnostic biopsies may well become redundant. [Copyright &y& Elsevier]

Even though being a rare condition in the era of antibiotic treatment, complications of acute frontal sinusitis still pose a potentially life-threatening problem. We present a clinical case series using a combined surgical approach. Within a 7 year period, all patients with a suppurative complication of an acute frontal sinusitis were included into this retrospective study and evaluated concerning histories, diagnostic and therapeutic procedures and achieved outcomes. Twelve patients (11–74 years) were identified; this corresponds to 0.3% of all patients that have undergone paranasal sinus surgery and 15.4% of all patients with infectious complications of sinusitis. The cases could be subdivided as follows: intracranial complications (4/12), osteomyelitis of the frontal bone (4/12), frontal/orbital soft tissue involvement (3/12) and endoluminal empyema (1/12). These were all correctly diagnosed by CT and (especially in the cases of intracranial complications) MRI. The microbiological spectrum comprised mostly non-multiresistant Staphylococci and Streptococci. All patients received aggressive antibiotic and combined surgical treatment. Within a mean follow up period of 32 months, the disease-related mortality and the rate of severe long-term ailment was 0%. If detected and treated early, both long-term morbidity and mortality can be minimised. A close cooperation with the related specialties (neurosurgery, ophthalmology, radiology) is thereby of utmost importance. [ABSTRACT FROM AUTHOR]

Objective: Unlike for other types of malignancies, the incidence and mortality rates of cancers of the upper aerodigestive tract (UADT) have been remaining static for the last decades. An improved early diagnosis of these malignant mucosal lesions and their precursors may help to lead to a reduction in both rates. It seems possible that this goal can be reached using a combination of non-invasive optical diagnostic methods. Material and methods: Different optical methods were investigated in groups of patients (n=15–80) with, or at high risk of developing a mucosal malignancy of the UADT: autofluorescence imaging (AFI; n=80) and enhanced fluorescence imaging (EFI; n=79) using 5-aminolevulinic acid (5-ALA)-induced protoporphyrin IX (PpIX) as tools for optical screening; multiple fluorophore analysis (MFA; n=18) and elastic scattering spectroscopy (ESS; n=25) as “optical biopsy” methods; optical coherence tomography (OCT; n=34) as a method to investigate the depth of a lesion, i.e. to differentiate hyperplasia/dysplasia from early invasive cancer. Results: When AFI or EFI was used in conjunction with conventional examination procedures, the detection of dysplastic or early malignant lesions was markedly improved (6 additional lesions for AFI vs. 7 for EFI). Additionally, the lesions were far easier to delineate against innocuous mucosa under fluorescence imaging. For both spectroscopic methods (MFA and ESS), it was possible to prove their feasibility to be able to differentiate between normal and cancerous mucosa (MFA: sensitivity 100%/specificity 94.4%; ESS: sensitivity 70.0%/specificity 78.8%). Using OCT, surface structures such as the keratin and epithelial layer, the epidermal–dermal junction and areas of cellular crowding were clearly identifiable and showed a good correlation to the histopathological slides to a depth of approximately 1.5mm. Of 34 lesions investigated so far, 2 out of 2 early malignant lesions as well as 29 out of 32 non-/premalignant lesions could be correctly differentiated using OCT. Conclusion: Even though the results are so far based on a very limited number of patients, the optical diagnostic methods presented here appear to be very helpful for the detection, differentiation and mapping of precancerous and early malignant mucosal lesions of the UADT. They hold great promise for improving early tumor diagnosis particularly when they are used in combination. [Copyright &y& Elsevier]

Introduction: For reasons of practicability, fiber-controlled diode lasers are preferred to conventional laser systems for endonasal applications. This study compares coagulative tissue effects using 1470 and 940nm lasers in treatment of hyperplastic inferior nasal turbinates. Methods: Twenty patients underwent laser coagulation for hyperplastic inferior nasal turbinates in this prospective, randomized, double blind, clinical study. In each case one nasal cavity was treated using 1470nm laser (3W power), the other with 940nm laser (10W power), endoscopically controlled in non-contact mode. Clinical presentation and the healing process were documented preoperatively and on days 1, 3, 7, 14 and 21 postoperatively by rhinomanometry, a standardized questionnaire and separate photo documentation. Results: Mean duration of the operative treatment was 2.54min using 1470nm laser and 3.30min using 940nm laser amounting to 125 and 816J total energy per turbinate, respectively. No infections, hemorrhages or other complications occurred intra- or postoperatively. Postoperative findings of the side treated with 1470nm laser showed significant reduction of scab formation (p<0.01) and an improvement in healing (p<0.05) compared to the other side. Conclusion: The use of 1470nm diode laser systems is an efficient method for tissue reduction in hyperplasia of nasal turbinates. Comparing 1470 and 940nm diode laser application, 1470nm laser application offered similar tissue reduction using less total energy with reduced scab formation and improved healing postoperatively. [Copyright &y& Elsevier]