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Endoscopic surgery of the skull base has been on the rise for several years. Endoscopic access for surgery can be achieved from the frontal sinus anteriorly along the skull base to the odontoid process posterior inferiorly. An endoscope is inserted through one nasal corridor and allows visualization of the working field and up to three surgical instruments can be used to address the lesion. This is called the 'two nostrils-four hands technique'. This is a retrospective study of 67 cases. Setting of the study is an Amsterdam University hospital. Cases were identified in the department of otorhinolaryngology and department of neurosurgery database. All patients operated between 1 January, 2008 and 1 February, 2012 with pituitary tumours that extend beyond the sella, sinonasal tumours and all non-pituitary skull-base tumours were included. Mean tumour diameter was 3.8 cm. We performed a near-to-gross total resection in 92 % of cases where we intended to perform a total resection. The most frequent complication was CSF leakage. This study demonstrates that this technique is safe and reliable. What is needed is a dedicated team, which includes a dedicated anesthesiologist, endocrinologist, ophthalmologist, and radiation oncologist. [ABSTRACT FROM AUTHOR]

Introduction: Although significant experience has been gained in the technical nuances of endoscopic sinus surgery procedures, the patient-reported outcomes of frontal endoscopic sinus surgery procedures are still poorly understood. In this study we used the validated patient outcome measure Sino Nasal Outcome Test-22 (SNOT-22) to assess the preoperative and postoperative quality of life in patients undergoing extended endoscopic frontal sinus surgery (Draf type 2 and Draf type 3 procedures). Methods: Out of a total of 680 patients undergoing endoscopic sinus and skull base surgery and 186 patients undergoing frontal sinus surgery, 99 chronic rhinosinusitis patients with (CRSwNP) or without (CRSnNP) nasal polyps undergoing Draf 2 or Draf 3 were assessed. Results: The mean preoperative SNOT-22 was 45.6 points for patients undergoing Draf 2 and 59 for patients undergoing Draf 3, while the mean radiological Lund–Mackay Score was 14.3 and 14.5, respectively. Mean SNOT 22 improvement was 22.9 points for Draf 2 and 37 points for Draf 3 respectively and remained significant in all time intervals, including at 4 years after surgery. With the exception of loss of smell/taste, all symptoms improved by a far bigger extent in Draf 3 group, despite the considerably worse starting point. Effect size (Cohen / Standard Deviations) of Draf 3 was greatest in the following symptoms: "being frustrated/restless/irritable" (1.63), "nasal blockage" (1.43), "reduced concentration" (1.35), "fatigue" (1.29) "runny nose" (1.26) and "need to blow nose" (1.17). Frontal sinus (neo) ostium was patent (fully or partly) at last follow up in 98% of Draf 2 patients and in 88% of patients following Draf 3. Patients with non-patent frontal (neo-) ostium however had a mean postoperative SNOT 22 score of 43 compared to 20 of those with patent frontal sinus (neo-) ostium, although the difference was not statistically significant. Conclusion: Patients undergoing Draf 3 have a greater burden of disease, including both nasal and emotional/general symptoms compared to Draf 2 patients; surgery results in improvement in both groups, although Draf 3 patients have the greatest benefit, especially in emotional / general symptons. In this way both groups achieve similar postoperative quality of life, despite the different starting points. [ABSTRACT FROM AUTHOR]

Key Clinical Message: In cases adjacent to critical structures, such as the internal carotid artery, surgeons should meticulously explore the feasibility of surgery before declaring the neoplasm unresectable. Salvage treatment for locally recurrent carcinoma of the nasopharynx constitutes a unique challenge. Surgery remains the gold standard treatment modality. Endoscopic nasopharyngectomy is considered a safe and feasible procedure overcoming the morbidities of an open surgery. Tumor adjacency to the internal carotid artery (ICA) is not an absolute contradiction for the endoscopic approach. Even in cases adjacent to critical structures, surgeons should meticulously explore the feasibility of surgery before declaring the neoplasm unresectable. We present the case of a 56‐year‐old male with locally recurrent adenoid cystic carcinoma (AdCC) of the nasopharynx adjacent to the ICA treated with endoscopic nasopharyngectomy. [ABSTRACT FROM AUTHOR]

The frontal sinus medial drainage —Draf Type III (modified endoscopic Lothrop) procedure, has become a cornerstone in frontal sinus surgery over the last three decades. Despite its widespread acceptance, challenges such as restenosis and neo-ostium closure persist, prompting the exploration of various preventive techniques. In this retrospective study, we analyzed data from 111 patients who underwent the Draf III procedure between November 2015 and November 2023, with a mean follow-up period of 3 years and 11 months. Approximately two-thirds of patients (64%) had undergone previous sinus surgery and 16% a previous Draf III. Over half of the patients had inflammatory conditions, with the majority being chronic rhinosinusitis with nasal polyps (CRSwNP) (46%), while 15% were diagnosed with malignant sinonasal tumors, and 23% with benign sinonasal tumors, of which the commonest was osteoma, accounting for 14 cases. The mean follow-up period was 3 years and 11 months. We focused on evaluating the efficacy of mucosal flaps and free grafts in preventing neo-ostium closure. Although it appears that there is no statistically significant correlation between flap usage and the need for revision surgery or ostium patency maintenance overall, subgroup analysis highlighted the benefits of flap reconstruction in patients with chronic rhinosinusitis with nasal polyps. In this subgroup, the use of flaps or grafts reduced the rate of neo-ostium stenosis from 20% to 0% (p < 0.05). Overall revision rate was 11.7%—however this was 8% in patients without acute inflammation at the time of surgery and went up to 31% in the presence of pus in the frontal recess (p = 0.02). This study contributes to the existing literature by providing insights into long-term outcomes, the enduring effectiveness of interventions in frontal sinus surgery, and especially the importance of taking into account the underlying pathology when assessing long-term outcomes. [ABSTRACT FROM AUTHOR]

Objective: To map Greek academic otolaryngologists, and assess gender, age and location-related differences in their rank and academic productivity. Methods: A pre-established database of local and diaspora scientists was used, after adjustment and updating for otolaryngology. The following data were recorded: age, gender, academic rank, country of work, total citations and h-index of December 2022. Results: A total of 276 Greek academic otolaryngologists were identified in the Scopus database. Of Greek otolaryngologists, 15.9 per cent are women. Of all academic otolaryngologists, 27.1 per cent have a university post, but only 4 per cent of them are women. There is an almost linear correlation between university post ranking and citations. Otolaryngologists based in Greece accounted for 3 out of the 10 most cited Greek otolaryngologists. Conclusion: There are significant age, gender and location-related differences in academic output. The representation of women and the full use of their potential in medicine require proactive measures, to lift the burdens limiting their participation. [ABSTRACT FROM AUTHOR]

Objective Nasal cavity and paranasal sinuses host a variety of malignant tumors with adenoid cystic carcinoma (ACC) being the most frequent cancer of salivary gland origin. The histological origin of such tumors virtually precludes primarily intracranial localization. The aim of this study is to report cases of primarily intracranial ACC without evidence of other primary lesions at the end of an exhaustive diagnostic workup. Methods An electronic medical record search complemented by manual searching was conducted to identify prospective and retrospective cases of intracranial ACCs treated in Endoscopic Skull Base Centre Athens at the Hygeia Hospital, Athens from 2010 until 2021 with a mean follow-up time of at least 3 years. Patients were included if after complete diagnostic workup there was no evidence of a nasal or paranasal sinus primary lesion and extension of the ACC. All patients were treated with a combination of endoscopic surgeries performed by the senior author followed by radiotherapy (RT) and/or chemotherapy. Results Three unique illustrative cases (ACC involving the clivus, cavernous sinus and pterygopalatine fossa, one orbital ACC with pterygopalatine fossa and cavernous sinus involvement and one involving cavernous sinus, and Meckel's cave with extension to the foramen rotundum) were identified. All patients underwent subsequently proton or carbon-ion beam radiation therapy. Conclusions Primary intracranial ACCs constitute an extremely rare clinical entity with atypical presentation, challenging diagnostic workup and management. The design of an international web-based database with a detailed report of these tumors would be extremely helpful. [ABSTRACT FROM AUTHOR]

Purpose: The DRAF III procedure has been used for access to the lateralmost part of the frontal sinus. We sought to identify anatomical and radiological measurements as well as modifications that predict the lateral limits of visualization and surgical access after this procedure. Methods: Seven cadaver heads were imaged with computed tomography scan. The distance from midline to the medial orbital wall (MOWD), midline to the lateral end of the frontal sinus (MLD), the sum of MLDs (SMLD), interorbital distance (IOD) and the shortest anteroposterior distance of the frontal recess (APD) were utilized. The ratios MLD/MOWD, and SMLD/IOD were calculated. The same distances were measured on 41 CT scans. Orbital transposition (OT) and partial resection of the piriform aperture (PAR) were performed; the visualization and reach were assessed. The angle of insertion was measured before and after the modifications. Results: Only the ratio MLD/MOWD was consistently predictive of access to the lateral, superior and posterior wall of the frontal sinus. Following the modifications, a visualization of 100% laterally was achieved with the 30- and 45 degree endoscopes and every lateral recess could be reached with the 70 degree suction. A mean increase of the angle of insertion of 25.3 and 59.6% was recorded after OT and PAR, respectively. Conclusions: IOD rather than APD defines the limits of the Draf III approach to the lateral frontal sinus and MLD/MOWD ratio can serve as a useful preoperative tool. Along to the already described OT, PAR increases visualization and reach of the lateral frontal sinus. [ABSTRACT FROM AUTHOR]

By virtue of being a (primarily) aesthetic rather than a functional procedure, rhinoplasty is unique among rhinological operations. As such, it raises moral, philosophical and social issues that no other procedure does. The preoperative assessment of a rhinoplasty patient includes a number of considerations that are unique in this type of surgery; during the outpatient consultation, the patient's motivation for surgery, stability and overall psychological evaluation, with a special emphasis on body dysmorphic disorder, have to be taken into consideration. Body dysmorphic disorder is a relatively common obsessive-compulsive spectrum disorder defined by a constant and impairing preoccupation with imagined or slight defects in appearance. Body dysmorphic disorder is associated with poor quality of life, extremely high rates of suicide and-following cosmetic surgery-high rates of dissatisfaction, occasionally manifesting as aggressiveness. A combination of psychological and medical management is the treatment of choice and this review aims to address the frequently controversial rhinoplasty indications for these patients. [ABSTRACT FROM AUTHOR]

Skull base surgery has gone through significant changes with the development of extended endoscopic endonasal approaches over the last decade. Initially used for the transphenoidal removal of hypophyseal adenomas, the endoscopic transnasal approach gradually evolved into a way of accessing the whole ventral skull base. Improved visualization, avoidance of brain retraction, the ability to access directly tumours with minimal damage to critical neurosurgical structures as well lack of external scars are among its obvious benefits. However, it presents the surgeons with a number of challenges, including the need to deal endoscopically with potential arterial bleeding, complicated reconstruction requirements as well as the need for a true team approach. In this review drawing from our experience as well as published series, we present an overview of current indications, challenges and limitations of the expanded endonasal approaches to the skull base. [ABSTRACT FROM AUTHOR]

This systematic review evaluates the efficacy and safety of biologicals for chronic rhinosinusitis with nasal polyps (CRSwNP) compared with the standard of care. PubMed, Embase, and Cochrane Library were searched for RCTs. Critical and important CRSwNP‐related outcomes were considered. The risk of bias and the certainty of the evidence were assessed using GRADE. RCTs evaluated (dupilumab‐2, omalizumab‐4, mepolizumab‐2, and reslizumab‐1) included 1236 adults, with follow‐up of 20–64 weeks. Dupilumab reduces the need for surgery (NFS) or oral corticosteroid (OCS) use (RR 0.28; 95% CI 0.20–0.39, moderate certainty) and improves with high certainty smell evaluated with UPSIT score (mean difference (MD) +10.54; 95% CI +9.24 to +11.84) and quality of life (QoL) evaluated with SNOT‐22 (MD −19.14; 95% CI −22.80 to −15.47), with fewer treatment‐related adverse events (TAEs) (RR 0.95; 95% CI 0.89–1.02, moderate certainty). Omalizumab reduces NFS (RR 0.85; 95% CI 0.78–0.92, high certainty), decreases OCS use (RR 0.38; 95% CI 0.10–1.38, moderate certainty), and improves high certainty smell (MD +3.84; 95% CI +3.64 to +4.04) and QoL (MD −15.65; 95% CI −16.16 to −15.13), with increased TAE (RR 1.73; 95% CI 0.60–5.03, moderate certainty). There is low certainty for mepolizumab reducing NFS (RR 0.78; 95% CI 0.64–0.94) and improving QoL (MD −13.3; 95% CI −23.93 to −2.67) and smell (MD +0.7; 95% CI −0.48 to +1.88), with increased TAEs (RR 1.64; 95% CI 0.41–6.50). The evidence for reslizumab is very uncertain. [ABSTRACT FROM AUTHOR]

Background: After internal carotid artery (ICA) injury during endoscopic skull base surgery, the majority of patients undergo ICA embolization or stenting to treat active extravasation or pseudoaneurysm development. However, management practices when embolization or stenting is not required have not been well described. The objective of this study was to determine how patients with ICA injury but no embolization, stenting, or ligation do long‐term and ascertain the reconstruction methods utilized. Methods: Twenty‐nine cases of ICA injury were identified in an international multi‐institutional retrospective review. Of these, we identified six cases that were not treated with embolization, stenting, or ICA sacrifice. Information was available for five cases. Results: A muscle patch was used in the immediate repair of each case. A nasoseptal flap was used in one case. Prefabricated nasal tampons were used in all cases. Nasal packing was initially left in for a median of 7 days prior to removal. The initial muscle patch was reinforced with a second muscle graft in one case. One case demonstrated ICA bleeding at the time of packing removal and was repacked an additional week. Follow‐up for each of these cases was at least 2 years. No cases of subsequent carotid rupture were found and none of these cases ultimately underwent endovascular stenting. Radiation or proton therapy has not been subsequently used in any of these patients. Conclusions: This study details the reconstruction, lessons learned, and long‐term follow‐up for five cases of ICA injury not treated with embolization, stenting, or ligation. [ABSTRACT FROM AUTHOR]

A 55‐year‐old man presented with dysphagia and a sore throat. Oral examination revealed a firm nodular mass in the midline of the pharyngeal wall. The tumor was en‐bloc excised. Histopathology and immunohistochemistry confirmed the diagnosis of a tenosynovial giant cell tumor. [ABSTRACT FROM AUTHOR]

Purpose: Spontaneous skull base cerebrospinal fluid leaks occurring without any apparent cause are rare. But those patients that present such leaks simultaneously, or successively, in multiple locations are even rarer. Given the rarity of this condition, we collected data from other groups in a multicentre study to reach an adequate number of patients and draw some preliminary considerations. Methods: We carried out a multicentre retrospective study on a cohort of patients treated at third level hospitals in Italy, Spain, United Kingdom and Greece for multiple spontaneous-CSF leaks and we compared them with a control group of patients treated for recurrent spontaneous-CSF leaks. Data regarding clinical aspects, radiological findings, surgical techniques and outcome were collected and preliminary considerations on the results were discussed. Results: A total of 25 patients presented multiple simultaneous spontaneous CSF leaks while 18 patients fit with the criteria of recurrent spontaneous CSF leaks. Data analysis was conducted separately. Conclusions: Our understanding of the pathogenesis of this condition is currently very limited. A causative role of IIH may be present but the differences that emerged from the comparison with patients with recurrent fistulas seem to promote the possible role of other cofactors. A longer follow-up period is needed, and, in our opinion, prospective and multicentre studies are the only solution to seriously deal with such a complex topic. [ABSTRACT FROM AUTHOR]

Abstract: There has been a considerable increase in the diagnosis of allergic diseases over the last decades. Prevalence of allergies in high-income countries and urban areas appears higher than in rural environments. While environmental factors like pollution or nutrition can be important, it is more likely that in the end they have a small association with allergies. Childhood infections and exposure to certain microbial antigens on the other hand seem to present a strong negative correlation with allergies, and therefore the increase of the allergic burden in the Western world has been frequently related to a decline of childhood infections giving birth to the “Hygiene Hypothesis”. We address the issue with emphasis on the associated pathophysiology tightrope walking between the skepticism of the critics, which cast doubt on it, and the pilgrims’ belief of having discovered allergy's Holy Grail. [Copyright &y& Elsevier]

Sleep nasendoscopy was conceived at the Royal National Throat, Nose and Ear Hospital, UK in 1991, and has remained fully implemented in patient selection for targeted treatment of the spectrum of sleep-disordered breathing. The senior authors (B.T.K. and P.B.) have been performing sleep nasendoscopy together for over 10 years, and we look back at their decade’s experience. A retrospective audit study based on case notes was performed over a 10-year period (1995–2005) in a tertiary-referral practice setting. Case notes were retrieved on all patients who had undergone sleep nasendoscopy during the study period, and agreed data were extracted and analyzed. A total of 2,485 sleep nasendoscopies were performed in patients with a mean age of 44.1 years, a 4:1 male preponderance, and a mean body mass index of 27.3 kg m−2. Sleep nasendoscopy grading correlated well with apnoea–hypopnoea index and mean oxygen desaturation. Such grading helped us define and discuss treatment options with patients. After a median follow-up period of 518 days, 72% of patients reported feeling better; 26% of patients reported no change; and only 2% of patients reported feeling worse after treatment. Sleep nasendoscopy has proved to be a useful adjunctive method to identify the anatomical site of snoring, not to mention upper airway collapse, and remains integral to our tertiary-referral practice. It has allowed us quality assessment of the dynamic anatomy of sleep-disordered breathing that most closely and cost-effectively simulates the natural situation of patients. And for targeted treatment, such assessment has been fundamental. [ABSTRACT FROM AUTHOR]

Aims: To compare voice quality as defined by formant analysis using a sustained vowel in patients who have undergone a partial glossectomy with a group of normal subjects. Methods & Procedures: The design consisted of a single centre, cross-sectional cohort study. The setting was an Adult Tertiary Referral Unit. A total of 26 patients (19 males) who underwent partial glossectomy and 31 normal volunteers (18 males) participated in the study. Group comparisons using the first three formant frequencies (F1, F2 and F3) using linear predictive coding (Laryngograph Ltd, London, UK) were performed. The existence of any significant difference of F1, F2 and F3 between the two groups using the sustained vowel /i/ and the effects of other factors, namely age, first presentation versus recurrence, site (oral cavity, oropharynx), subsite (anterior two-thirds of the tongue, tongue base), stage, radiation, complication, and neck dissection, were analysed. Outcomes & Results: Formant frequencies F1, F2 and F3 were normally distributed. F1 and F2 were significantly different in normal males versus females. F1, F2 and F3 were not different statistically between male and female glossectomees. Comparison of only women showed significant differences between normal subjects and patients in F2 and F3, but none in F1. This was the opposite in men where F1 was significantly different. Age, tumour presentation, site, subsite, radiation and neck dissection showed no significant difference. Postoperative complications significantly affected the F1 formant frequency. Conclusions: The study found that the formant values in patients following a partial glossectomy were altered significantly as compared with the normal control subjects. Only gender and complications and not the age, site, subsite, radiation and neck dissection were seen to influence the formant scores. [ABSTRACT FROM AUTHOR]

In the original publication of the article, the following affiliation "Medical school, University of Nicosia, Nicosia, Cyprus" of the author "Christos Georgalas" was missed and included in this correction. [ABSTRACT FROM AUTHOR]

Objective: Skull base anatomy around the internal carotid artery (ICA) is extremely complex. Among anatomical landmarks studied, the vidian canal has been thoroughly evaluated, unlike the vidian nerve (VN). Our aim is to evaluate the VN-ICA relationships, and understand their role in terms of surgical planning., Methods: Fifty MRI examinations of 100 healthy petro-spheno-clival regions were reviewed in order to evaluate the relationship between the vidian nerve axis (VNA) and the petrous ICA. Twenty-seven cases of expanded endonasal approaches to petrous apex region were evaluated to check the VN-ICA relationship intraoperatively., Results: MRI evaluations showed that, in 23% of cases, the VNA was below the edge of the ICA, in 45% it was at the edge of the ICA and in 32% it ended up above the edge of the ICA. Surgically speaking, in 9 of 28 petrous apex approaches, the VN ended above the inferior edge of the petrous carotid., Conclusions: MRI evaluation adds useful information in planning the surgical approach to petro-spheno-clival regions, even if the identification of VNA, in these cases, may not be radiologically possible. Surgical experience confirms the importance of VN identification in guiding the surgeon in complex cases, and also outline the possible risks of relying only on this landmark., (Copyright © 2024 Società Italiana di Otorinolaringoiatria e Chirurgia Cervico-Facciale, Rome, Italy.)

Objective: The role of elective neck dissection (END) in the management of clinical N0 (cN0) squamous cell carcinomas (SCC) of the sinonasal tract is unclear. In this systematic review, we evaluate the risk of occult nodal metastasis in sinonasal SCCs with cN0M0 tumors to support clinical decision making., Methods: A literature search was conducted in the following three electronic databases: Medline/PubMed, ScienceDirect, and Google Scholar. Articles were assessed for eligibility in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Two independent authors extracted the data. The Methodological Items for Non-Randomized Studies (MINORS) tool was used for the assessment of biases of each included study., Results: Our systematic review included six studies that met the inclusion criteria, all retrospective in design. The rate of histologically proven metastasis of sinonasal SCC to the clinically negative neck is 12.5%. Almost half of the positive cases are pathologically staged as N2 (6.5%)., Conclusion: Our systematic review provides the rate of sinonasal SCC occult metastasis to the neck so that the surgeons can discuss with patients the risks and possible merits of adding an elective neck management in the surgical plan., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Transoral Robotic Surgery (TORS) and radiotherapy are considered oncologically equivalent primary treatment options for early-stage HPV-positive oropharyngeal squamous cell carcinoma (OPSCC). Quality of Life (QoL) and Patient Reported Outcome Measures (PROMs) are therefore imperative in supporting clinical decision-making and optimising patient-centred care. The aim of this article is to evaluate how these primary treatment modalities compare in terms of QoL., Materials and Methods: Systematic review and meta-analysis of studies comparing primary TORS and primary radiotherapy for OPSCC using validated QoL tools. Swallowing and global QoL were the primary endpoints with secondary endpoints including all other QoL domains. An inverse variance random-effects model was employed to calculate the weighted estimate of the treatment effects across trials., Results: A total of six studies collectively reporting on 555 patients were included (n = 236 TORS and n = 319 radiotherapy). Meta-analysis showed no significant difference for swallowing (mean difference = -0.24, p = 0.89) and global QoL (mean difference = 4.55, p = 0.14). For the remaining QoL domains (neck/shoulder impairment, neurotoxicity, voice, xerostomia, speech, and distress), the scarcity of data did not permit meta-analysis. However, the existing data showed no significant difference for any except for xerostomia where TORS appears favourable in the sole study reporting on this., Conclusions: TORS and radiotherapy appear to be comparable primary treatment options for early stage OPSCC when it comes to QoL. However, a substantial proportion of patients in the TORS group received adjuvant (chemo)radiotherapy rendering it difficult to establish the 'true' QoL outcomes following surgery alone. There are also minimal studies reporting QoL outcomes beyond swallowing and global QoL. Further research is therefore needed, including more randomised trials adequately powered to detect differences in QoL outcomes., Competing Interests: Declaration of competing interest All authors; Keshav Kumar Gupta, Mriganka De, Thanos Athanasiou, Christos Georgalas and George Garas, have nothing to declare., (© 2024 Elsevier Ltd, BASO ∼ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights are reserved, including those for text and data mining, AI training, and similar technologies.)

Purpose: Posterior epistaxis is a common emergency in ENT practice varying in severity and treatment. Many management guidelines have been proposed, all of which are a product of retrospective analyses due to the nature of this pathology, as large-scale double-blind studies are impossible-even unethical-to conduct. The purpose of this review is to perform a thorough analysis and comparison of every treatment plan available and establish guidelines for the best possible outcome in accordance to every parameter studied. Given the extensive heterogeneity of information and the multitude of studies on this topic, along with the comparison of various treatment options, we opted for a literature review as our research approach., Methods: A review of the literature was performed using PubMed Database and search terms included "posterior epistaxis", "treatment", "management", "guidelines", "algorithm" "nasal packing", "posterior packing", "surgery", "SPA ligation", "embolization", "risk factors" or a combination of the above., Results: Initial patients' assessment invariably results in most cases in posterior packing. There seems to be a superiority in recent literature of early surgery over nasal packing as a definitive treatment. Embolization is usually used after surgery failure, except for specific occasions., Conclusion: Despite the vast heterogeneity of information, there seems to be a need for re-evaluation of the well-established treatment plans according to more recent studies., (© 2023. The Author(s).)

Purpose of Review: Benign bony lesions of the craniofacial complex are relatively common. However, their location close to critical neurovascular structures may render their treatment, if required, highly challenging.This article reviews the current literature on their pathophysiology, diagnosis, natural course and treatment, with a focus on most recent findings., Recent Findings: A new classification has been suggested concerning endoscopic resectability. The ratio of lateral frontal to interorbital distance can accurately and reliably predict the endoscopic reach to lateral frontal sinus, while orbital transposition can assist us in reaching lateral frontal sinus when anatomy is unfavorable. New and combined endoscopic transnasal and transorbital approaches are now in the surgical armamentarium. Prophylactic optic nerve decompression in fibrous dysplasia is absolutely contraindicated as it leads to worse visual outcomes. Radiotherapy of such lesions is of no benefit and may lead to a higher risk of malignant transformation. The presence of Guanine Nucleotide binding protein Alpha Stimulating (GNAS) mutation in chromosome 20 is universally present in fibrous dysplasia and can differentiate them from ossifying fibromas., Summary: Diagnosis and therapeutic management of benign craniofacial bone lesions remains challenging. If surgical treatment is contemplated, the morbidity of the intervention should always be weighed against the potential benefits. Evolution of extended endoscopic endonasal and transorbital surgery means that more lesions can be reached purely endoscopically with better oncological and cosmetic results., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

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., (© 2023 The Authors. International Forum of Allergy & Rhinology published by Wiley Periodicals LLC on behalf of American Academy of Otolaryngic Allergy and American Rhinologic Society.)

Introduction Nasal obstruction is one of the most frequently reported symptoms in clinical practice. The second most common cause of nasal obstruction is inferior turbinate hypertrophy, a nasal pathology for which surgical treatment is often required. This study aims to determine the most effective surgical method in patients with inferior turbinate hypertrophy (ITH). Materials and methods The study was performed from September 2018 to October 2019 in the Otolaryngology-Head and Neck Surgery Department of the Evangelismos Hospital of Athens. The study population comprised 205 patients that underwent surgery and were monitored in the hospital. Radiofrequency ablation (RFA) was the method used in 73 patients, 68 patients were treated with the microdebrider-assisted turbinoplasty (MAT), and the remaining 64 patients were operated on using electrocautery (EC). Following surgery, postoperative complications were assessed and quantified. Results Overall, 205 patients underwent surgery. The first group (n=73) was operated on using radiofrequency ablation and had a complication rate of 30.1%. Out of 73 patients, 51 recovered without complications. The remaining 22 had complications, consisting of 16 patients with bleeding and six with postnasal drip. The second group (n=68) was treated using the microdebrider method. The complication rate was 26.5%, where 50 patients did not present with any symptoms post-operatively and 18 exhibited symptoms. Specifically, postnasal drip was more prevalent with this method as all 18 patients showed postnasal drip as their complication. The third group (n=64) was treated with electrocautery. Patients in this group had the most complications (n=24), 16 were attributed to postnasal drip and eight to infections, treated promptly with oral antibiotics. The complication rate using this method was 37.5%. Conclusion In our study, the microdebrider-assisted turbinoplasty offered the lowest complication rate, followed by radiofrequency ablation and electrocautery. However, all three methods managed to alleviate the nasal obstruction and treat inferior turbinate hypertrophy. More research is needed as a lack of consensus remains regarding the optimal surgical technique for lower turbinate hypertrophy., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Karamatzanis et al.)

Objective: Biphenotypic sinonasal sarcoma (BSNS) is a rare low-grade cancer that was included from the 4th edition of WHO classification of head and neck tumours. The purpose of this study is to analyse clinical behaviour, pattern of recurrences and survival outcomes of this neoplasm., Methods: Retrospective review of patients affected by BSNS who were treated via an endoscopic-assisted approach in 6 European tertiary-care referral hospitals. Cases of BSNS described in literature since 2012 to date were fully reviewed, according to PRISMA guidelines., Results: A total of 15 patients were included. Seven patients were treated via an endoscopic endonasal approach, 4 with endoscopic transnasal craniectomy, and 4 via a cranio-endoscopic approach. Adjuvant treatment was delivered in 2 cases. After a mean follow-up of 27.3 months, systemic metastasis was observed in 1 case; the 5-year overall survival and disease-free survival rates were 100% and 80 ± 17.9%, respectively., Conclusions: BSNS is a locally aggressive tumour with a low recurrence rate and encouraging survival outcomes if properly treated with surgical resection and free margins followed by adjuvant radiotherapy for selected cases. Endoscopic-assisted surgery is safe and effective as an upfront treatment within a multidisciplinary care protocol., (Copyright © 2022 Società Italiana di Otorinolaringoiatria e Chirurgia Cervico-Facciale, Rome, Italy.)

Transorbital approaches are genuinely versatile surgical routes which show interesting potentials in skull base surgery. Given their "new" trajectory, they can be a very useful adjunct to traditional routes, even being a valid alternative to them in some cases, and add valuable opportunities in selected patients. Indications are constantly expanding, and currently include selected intraorbital, skull base and even intra-axial lesions, both benign and malignant. Given their relatively recent development and thus unfamiliarity among the skull base community, achieving adequate proficiency needs not only a personalized training and knowledge but also, above all, an adequate case volume and a dedicated setting. Current, but mostly future, applications should be selected by genetic, omics and biological features and applied in the context of a truly multidisciplinary environment., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Dallan, Cristofani-Mencacci, Fiacchini, Turri-Zanoni, van Furth, de Notaris, Picariello, Alexandre, Georgalas and Bruschini.)

Purpose of Review: Advances in anterior skull base surgery have resulted in the increasing diversification of reconstructive techniques. New vascularized flaps have been suggested in the last years, some quite similar, whereas new uses and applications have been suggested for some vascularized flaps, which have already established their value over the last decades. In this article, we describe the developments in skull base reconstruction with vascularized flaps and analyse the international experience in the use of vascularized flaps published with a focus on the last 18 months., Recent Findings: Over the past 18 months, a number of novel or modified vascularized intranasal flaps have been described, focusing on reconstruction of larger defects, the medial orbital wall, the anterior skull base (septal flip-flap) and dissection of the nasoseptal flap from the SPA foramen. Extranasal vascularized flaps, which have been around for a long time, still have their rightful place in skull base reconstruction and have recently been adjusted for endoscopic use., Summary: We present an overview of the latest developments in vascularized flaps (intranasal and extranasal), their new implications, their modifications and complications or predictions of viability., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Importance: Injury to the internal carotid artery (ICA) during endoscopic endonasal skull base surgery does not typically occur as an isolated circumstance but often is the result of multiple factors., Objective: To assess the factors associated with ICA injury in an effort to reduce its occurrence., Design, Setting, and Participants: This quality improvement study used a multicenter root cause analysis of ICA injuries sustained during endoscopic endonasal skull base surgery performed at 11 tertiary care centers across 4 continents (North America, South America, Europe, and Asia) from January 1, 1993, to December 31, 2018. A fishbone model was built to facilitate the root cause analysis. Patients who underwent an expanded endoscopic endonasal approach that carried a substantial potential risk of an ICA injury were included in the analysis. A questionnaire was completed by surgeons at the centers to assess relevant human, patient, process, technique, instrument, and environmental factors associated with the injury., Main Outcomes and Measures: Root cause analysis of demographic, human, patient, process, technique, instrument, and environmental factors as well as mortality and morbidity data., Results: Twenty-eight cases of ICA injury occurred during 7160 expanded endoscopic endonasal approach procedures (incidence of 0.4%). The mean age of the patients was 49 years, with a female to male predominance ratio of 1.8:1 (18 women to 10 men). Anatomical (23 [82%]), pathological (15 [54%]), and surgical resection (26 [93%]) factors were most frequently reported. The surgeon's mental or physical well-being was reported as inadequate in 4 cases (14%). Suboptimal imaging was reported in 6 cases (21%). The surgeon's experience level was not associated with ICA injury. The ICA injury was associated with use of powered or sharp instruments in 20 cases (71%), and use of new instruments or technology in 7 cases (25%). Two patients (7%) died in the operating room, and 3 (11%) were alive with neurological deficits. Overall, patient-related factors were the most frequently reported risk factors (in 27 of 28 cases [96%]). Factors associated with ICA injury catalyzed a list of preventive recommendations., Conclusions and Relevance: This study found that human factors were associated with intraoperative ICA injuries; however, they were usually accompanied by other deficiencies. These findings suggest that identifying risk factors is crucial for preventing such injuries. Preoperative planning and minimizing the potential for ICA injury also appear to be essential.

Purpose of Review: The purpose of this review is to present the most important recent developments concerning biologics as a therapeutic option for chronic rhinosinusitis (CRS)., Recent Findings: mAb anti-IL-4 receptor α (Dupilumab) was recently approved by Food and Drug Administration (FDA) for patients with CRSwNP and four other biologics are under investigation, with promising preliminary results., Summary: CRS is a disease associated with a significant symptom burden and high-indirect costs. Despite recent advances in combined approaches, persistent symptoms or recurrences are not uncommon. Monoclonal antibodies, used mainly to treat asthma, have recently been shown to have a positive impact on controlling the symptoms of CRS and reducing the need for endoscopic sinus surgery. Dupilumab, mepolizumab, reslizumab, benralizumab and omalizumab are discussed and their mechanism of action, risk and current evidence on efficacy are presented. Preliminary studies show encouraging results with relatively few side effects. Once the high cost of such therapies is addressed, they could prove an important adjuvant therapy for patients with CRS. Large-scale clinical trials designed to evaluate them are called for.

A best evidence topic was written according to a structured protocol. The question addressed was whether TransOral Robotic Surgery (TORS) is a safe and effective multilevel treatment for Obstructive Sleep Apnoea (OSA) in obese patients following failure of conventional treatment(s). A total of 39 papers were identified using the reported searches of which 5 represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Existing treatments for OSA - primarily CPAP - though highly effective are poorly tolerated resulting in an adherence often lower than 50%. As such, surgery is regaining momentum, especially in those patients failing non-surgical treatment (CPAP or oral appliances). TORS represents the latest addition to the armamentarium of Otorhinolaryngologists - Head and Neck Surgeons for the management of OSA. The superior visualisation and ergonomics render TORS ideal for the multilevel treatment of OSA. However, not all patients are suitable candidates for TORS and its suitability is questionable in obese patients. In view of the global obesity pandemic, this is an important question that requires addressing promptly. Despite the drop in success rates with increasing BMI, the success rate of TORS in non-morbidly obese patients (BMI = 30-35kgm -2 ) exceeds 50%. A 50% success rate may at first seem low, but it is important to realize that this is a patient cohort suffering from a life-threatening disease and no option left other than a tracheostomy. As such, TORS represents an important treatment in non-morbidly obese OSA patients following failure of conventional treatment(s).

Purpose of Review: Although chronic rhinosinusitis with nasal polyps, asthma, and allergy share common inflammatory mechanisms, there is no evidence of cause-and-effect relationship. In this review, we present new studies investigating the complex immunology that links these diseases. Advances in new therapies as well as evidence regarding indication and timing of surgery, especially of more complex cases, are highlighted., Recent Findings: New studies have endotyped patients in an effort to describe the exact inflammatory profile of each phenotype, whereas described cytokines seem to play a significant role in amplification of T2 inflammation, directly or via innate lymphoid cells. New mAbs that block specific cytokines of these pathways have been developed and seem to show reduced asthma severity as well as improved sinonasal outcomes. Moreover, it has been shown that operating early in the course of disease leads not only to bigger improvements in SNOT-22 outcomes but also to reduced asthma incidence postoperatively in refractory cases., Summary: Applying data from current studies in clinical practice, we could better manage refractory cases with asthma and polyps, both medically and surgically. Treatment has to be patient-centered, and this demands a multidisciplinary-team approach of the airway diseases.

Inverted papillomas may affect the (para)nasal cavity. While some of these papillomas can undergo malignant transformation, others grow slowly and cause few if any symptoms. An endoscopic approach is seen as providing a balance between the greatest removal possible and avoiding unnecessary morbidity. However, the actual long-term quality of life of patients having undergone surgery for inverted papillomas has never been studied. Our primary aim is to assess the long-term sequelae and the quality of life of patients after endoscopic surgery of sinonasal inverted papillomas. The secondary aim is to establish which nasal symptoms, if any, are the most prevalent before and after surgery. We used the SNOT-22 questionnaire to assess the quality of life of patients who had undergone endoscopic surgery for sinonasal inverted papillomas between 2000 and 2011. Twenty-seven out of 34 patients returned the questionnaire (79 % response rate). Median follow-up was 6 years (range 1-10). Mean age was 58.9 years (range 40-85). Median SNOT-22 score was 12, while the most frequent postoperative symptom was the need to blow the nose (18 patients) and the most frequent preoperative symptom was nasal obstruction. Patients after endoscopic removal of sinonasal inverted papillomas return to an almost normal quality of life, as measured by the disease-specific questionnaire SNOT-22. The most frequent symptom was the need to blow the nose.

Background: Surgical resection represents the gold standard for the treatment of sinonasal malignancies. This study reviewed the published outcomes on endoscopic surgery or endoscopic-assisted surgery versus open approach for the management of sinonasal adenocarcinomas., Methods: PubMed, EMBASE, the Cochrane Library, and CENTRAL electronic databases were searched for English language articles on endoscopic surgery, endoscopic-assisted surgery, and open approach for sinonasal adenocarcinomas. Each article was examined for patient data and outcomes for analysis., Results: Thirty-nine articles including 1826 patients were used for the analysis. The endoscopic surgery and endoscopic-assisted surgery showed low rates of major complications (6.6% and 25.9%, respectively) compared to open approaches (36.4%; p < .01). The incidence of local failure was lower in the endoscopic surgery group as compared with open approach patients (17.8% vs 38.5%; p < .01, respectively). The multivariate Cox regression model showed a worst overall survival related to advanced T classification and open approach., Conclusion: From the existing body of data, there is growing evidence that endoscopic nasal resection is a safe surgical option in the management of sinonasal adenocarcinomas. © 2015 Wiley Periodicals, Head Neck 38: E2267-E2274, 2016., (© 2015 Wiley Periodicals, Inc.)

Objectives/hypothesis: We report on the treatment outcome of endoscopically managed sinonasal inverted papilloma, focusing on revision cases. Our aim was to identify the properties of revision cases that affect treatment outcome by comparing them to primary cases in a single center. We propose using 5-fluorouracil (5-FU) in the postoperative management of inverted papilloma., Study Design: A retrospective single-center case series. This study met the criteria for approval by the local medical ethics committee., Methods: We performed a retrospective chart review identifying patients operated on between January 2003 and September 2013. Data were collected about patient demographics, symptoms, tumor attachment site, imaging, intraoperative and pathological findings, surgical approaches, postoperative treatment, follow-up, and recurrence., Results: One hundred and twenty-one (72 revision and 49 primary) cases were retrieved with a minimum follow-up of 1 year. Revision cases have significantly higher Krouse staging (P = 0.003), different distribution of tumor attachment sites, and higher recurrence rates. The recurrence rate was 4.1% for primary cases (mean follow-up 35.5 months) and 18.1% for revision cases (mean follow-up 45 months). Eight of the recurrent cases recurred within the first year. 5-fluorouracil was applied postoperatively in 18 (5 primary and 13 revision) cases, which included one (5.6%) recurrence and one minor complication (transient periorbital swelling)., Conclusion: The most important factors in preventing the recurrence of inverted papilloma are the determination of the location of the attachment and the completeness of resection in the primary endoscopic surgery. Revision cases have a higher recurrence rate, and the attachment sites are surgically more challenging. The use of 5-FU might have a place in the postoperative treatment of surgically challenging inverted papilloma., Level of Evidence: 4., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)