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Chronic rhinosinusitis (CRS) is characterized by mucosal inflammation affecting both the nasal cavity and paranasal sinuses; its causes are potentially numerous, disparate, and frequently overlapping. The more common conditions that are associated with CRS are perennial allergic and nonallergic rhinitis, nasal polyps, and anatomical mechanical obstruction (septum/turbinate issues). Other less common etiologies include inflammation (eg, from superantigens), fungal sinusitis or bacterial sinusitis with or without associated biofilm formation, gastroesophageal reflux, smoke and other environmental exposures, immune deficiencies, genetics, and aspirin-exacerbated respiratory disease. A diagnosis of CRS is strongly suggested by a history of symptoms (eg, congestion and/or fullness; nasal obstruction, blockage, discharge, and/or purulence; discolored postnasal discharge; hyposmia/anosmia; facial pain and/or pressure) and their duration for > 3 months. A definitive diagnosis requires physical evidence of mucosal swelling or discharge appreciated during physical examination coupled with CT imaging if inflammation does not involve the middle meatus or ethmoid bulla. Multivariant causation makes the diagnosis of CRS and selection of treatment complex. Furthermore, various types of health care providers including ear, nose, and throat (ENT) specialists, allergists, primary care physicians, and pulmonologists treat CRS, and each is likely to have a different approach. A structured approach to the diagnosis and management of CRS can help streamline and standardize care no matter where patients present for evaluation and treatment. A 2008 Working Group on CRS in Adults, supported by the American Academy of Otolaryngic Allergy (AAOA), developed a series of algorithms for the differential diagnosis and treatment of CRS in adults, based on the evolving understanding of CRS as an inflammatory disease. The algorithms presented in this paper address an approach for all CRS patients as well as approaches for those with nasal polyps, edema observed on nasal endoscopy, purulence observed on nasal endoscopy, an abnormal history and physical examination, and an abnormal history and normal physical examination.

New technologies continue to affect the practice of otolaryngology-head and neck surgery. Numerous financial and regulatory barriers must be overcome to develop an idea into a useful device or intervention. US Food and Drug Administration (FDA) approval focuses on safety, often leaving the medical community, in general, to determine the efficacy of the device after FDA approval has been granted. Physicians are involved throughout the technology development process, generating conflicts of interest that must be effectively managed. It is essential that physicians ethically maintain their leadership in developing and evaluating new advances in medical technology.

Immunologic response to fungal antigens has been cited as an etiologic factor in chronic rhinosinusitis (CRS). Previous work demonstrated a significant cytokine response in CRS patients that did not correlate with an immunoglobulin E (IgE) response. This study was performed in an effort to replicate these findings in a more geographically diverse population.Prospective in vitro study.Two academic tertiary rhinologic practices in Texas and Utah.Serum and peripheral blood monocytes (PBMC) were obtained from 10 CRS patients and seven controls. Total IgE and fungal-specific IgE levels were determined. Cytokine levels were measured after PBMC exposure to Alternaria, Aspergillus, Cladosporium, and Penicillium extracts. Correlations between cytokine responses and presence of CRS as well as IgE and IgG were determined.Interleukin-5 (IL-5) was produced after Alternaria extract exposure in both CRS patients and controls, but the production was heterogenous and did not correlate with the presence of CRS. IL-5 levels after Alternaria extract exposure correlated strongly with levels of Alternaria-specific IgE in both CRS patients and controls. IL-5 production did not correlate with IgG levels. IL-4, IL-13, and interferon-gamma production did not differ between CRS patients and controls.In contrast to previously reported data, IL-5 responses to Alternaria extract were not predictive of CRS presence. Our results in patients from Utah and Texas significantly differ from previously published findings in predominantly Midwestern patients. The immunologic response to fungal extracts appears to be heterogenous and may differ based on geography, allergy status, and/or other as-yet unknown factors.

Rhinologic literature has historically relied on lower levels of evidence to make prescriptive recommendations for use of new technology and procedures. However, as the medical profession has moved to embrace the principles of evidence-based medicine, expectations for minimum standards of evidence have risen. The resulting high-quality efficacy outcomes data have become the linchpin of informed decision making by physicians, payers, and health care systems. While many challenges remain in this transition to higher evidence expectations, none are insurmountable. It has become the responsibility of the organized medical profession to play a role in influencing and supporting production of high-quality outcomes research.

Objectives: Stenting of the frontal sinus outflow tract is occasionally used following surgery to prevent stenosis. The optimal length of stent retention has not been defined and some experts advocate up to 6 months prior to removal. The tolerance of even longer periods of stenting is unknown. Study Design: Retrospective review. Methods: We identified adult patients in a tertiary rhinology practice with frontal sinus stents placed between July 2000 and December 2006 and in place at least 6 months. Length of stenting and condition at last follow-up were determined. Results: During the 6-year study period, 10 frontal sinus stents were placed out of over 450 endoscopic frontal sinus surgery procedures. Each patient had only one stent placed. Of these 10 patients, one was excluded because the stent was electively removed at eight weeks. None of the remaining nine has been lost to follow-up. The mean length of stenting was 32.6 months (median 17, range 11 to 73). One patient had the stent removed at 61 months because of infection. Another had the stent removed at 11 months because of pain and edema. The remaining seven patients remain asymptomatic with patent stents and no granulation tissue seen on nasal endoscopy. Conclusions: In this group, long-term frontal stenting was rarely used but relatively well tolerated with only two of nine patients requiring removal up to 6 years after placement. With the optimal length for frontal stenting unknown, risks and benefits of removal at each evaluation point must be weighed. Laryngoscope, 119:190–192, 2009

Background Juvenile nasopharyngeal angiofibromas (JNAs) are rare benign lesions that express hormonal receptors. This report describes a recurrence of a JNA 20 years after excision associated with exogenous testosterone therapy. Methods A 36-year-old man developed a sphenoid mass 20 years following resection of a JNA, shortly after initiating exogenous testosterone therapy for symptomatic low endogenous testosterone. Results The mass was subsequently excised and was histologically consistent with a JNA. The patient resumed his testosterone therapy postoperatively. Repeated imaging has demonstrated no recurrence after 3 years. Conclusion This unique case adds further evidence to the role of testosterone in the pathogenesis of JNAs. Exogenous testosterone can cause tumor regrowth at any time, even decades following treatment. The patients with a history of JNA, even those without recurrence for years, should weigh the risk of recurrence before the use of exogenous testosterone. © 2009 Wiley Periodicals, Inc. Head Neck, 2010

Adhesion of the middle turbinate to the lateral nasal wall is a common complication of endoscopic sinus surgery. The potential sequela of middle turbinate lateralization is obstruction of the middle meatus and the maxillary, ethmoid, or frontal sinuses, which can result in recurrent sinus disease and often necessitate revision surgery. While various materials and stents have been developed to prevent middle turbinate adhesion to the lateral nasal wall, suture medialization of the middle turbinate to the nasal septum with an absorbable suture has the potential to be just as successful without causing the discomfort associated with other methods. We conducted a retrospective review of suture medializations of 157 middle turbinates in 85 patients who had undergone endoscopic sinus surgery to ascertain the incidence of postoperative middle turbinate adhesion to the lateral nasal wall. We found that adhesions developed in 17 middle turbinates (10.8%) in 15 patients; the remaining 140 middle turbinates (89.2%) were free of scarring. Thirteen of the 17 adhesions were easily divided in the outpatient clinic setting during routine postoperative endoscopic care, meaning that only 4 of the 157 turbinates (2.5%) demonstrated synechiae that remained problematic after routine care. We conclude that the development of clinically significant adhesions following suture medialization of the middle turbinate is uncommon. Suture medialization should be considered as an alternative to middle meatal packing or stenting to prevent adhesions following endoscopic sinus surgery.

• Revision sphenoid sinus surgery is usually most easily performed after a complete ethmoidectomy.

The development of novel biointeractive hydrogels for tissue engineering1, 2, 3, tissue repair, and release of drugs4 and growth factors5 has attracted considerable attention over the past decade. Our attention has focused on hydrogels based on the extracellular matrix (ECM), a heterogeneous collection of covalent and noncovalent molecular interactions comprised primary of proteins and glycosaminoglycans (GAGs)6. In the ECM, covalent interactions connect chondroitin sulfate (CS), heparan sulfate (HS) and other sulfated GAGs to core proteins forming proteoglycans (PGs). Noncovalent interactions include binding of link modules of PGs to hyaluronan (HA), electrostatic associations with ions, hydration of the polysaccharide chains, and triple helix formation to generate collagen fibrils.

Background: Biomaterials based on hyaluronan (HA) are currently used after sinus surgery but have not been found to decrease scarring or enhance wound healing. Chemical composition of these modified HA molecules may impact their biological and clinical effects. Objective: To analyze chemical variations of a single crosslinked HA-based hydrogel, chemically modified thiolated HA (CMHA-SX). Methods: Four different components of the hydrogel composition were altered, yielding 54 variations. These were subjected to biomechanical testing, and then potential clinically relevant variations were further tested for swelling and degradation characteristics. Using a rabbit maxillary sinus model, the ability of the material variations to stent a neo-ostium was tested. Histologic measures were also assessed. Biomechanical and biological effects were correlated. Results: Minor compositional changes had profound biomechanical and biological effects. Swelling and rate of enzymatic degradation were closely related. CMHA-SX hydrogels that were the most effective stents in maintaining the neo-ostium also generated the lowest level of acute inflammation, as determined by histology. Conclusions: Chemical composition has a significant impact on the clinical potential of modified HA materials. Histocompatibility appears to most significantly affect ostium preservation. Significance: Different CMHA-SX hydrogels perform differently in vivo, even when the chemical compositions are quite similar. Objective prospective testing of modified HA materials should precede their clinical use in sinus surgery.

Background Evidence-based medicine calls for a critical evaluation of the scientific evidence for treatments of disease. This report synthesizes the available evidence supporting the indications for image guidance in sinus surgery, examining two important questions: (1) Does image-guided sinus surgery (IGSS) reduce complication rates? (2) Does IGSS improve clinical outcomes? Methods Primary research articles evaluated for this report were identified using appropriate search terms and a PubMed search. Two authors independently reviewed each article. Articles were assigned an evidence level based on accepted guidelines: level 1 = randomized trials, level 2 = prospective cohort studies with comparison group, level 3 = case-control studies, level 4 = retrospective case series, and level 5 = expert opinion. Results We identified 105 articles for full review and highlight 5 articles in our report. Primarily, there is expert opinion (level 5) and case series (level 4) with and without comparison groups supporting the indications for IGSS. In addition, authors point out that sample size and design issues preclude definitive randomized trials using IGSS. Conclusion Although randomized trials of IGSS are not practical, ethical, or feasible, clinical experience, expert opinion, and case series support the current indications for IGSS. Studies designed to draw conclusions about the role of IGSS in decreasing major complications of sinus surgery are not possible.

Purpose of review Biomaterials are frequently used in the paranasal sinuses to control bleeding, promote tissue regeneration, improve healing, or prevent scarring. Few, however, have been prospectively examined in a peer-reviewed format prior to commercialization. This paper examines recent advances in biomaterials used in surgical rhinology and especially highlights some 'postmarketing' concerns. Recent findings Three biomaterials have received recent attention. The use of hydroxyapatite cement within the frontal sinus has been questioned due to recent data regarding late infection and exposure. Thrombin-gelatin paste has been shown to be effective in controlling bleeding following sinus surgery but there are conflicting data about its effect on increased scarring. Hyaluronan derivatives have also received attention, with scarring concerns again raised. Importantly, it appears that the chemical modifications of the starting material may have a significant impact on compatibility and function. Summary Surgeons must be aware of the potential risks and limitations of biomaterials used in rhinology. While recent and future advances in biomaterials will likely improve patients' outcomes in sinus diseases, it is apparent that currently available materials may only be a first step to that goal. More rigorous prospective evaluation of biomaterials should guide their use in the paranasal sinuses.

Background The aim of this study was to determine access to, usage of, and attitudes toward image guidance in endoscopic sinus and anterior skull base surgery. Methods We performed a survey of American Rhinologic Society members. Results Of 1050 surveys mailed, 340 (32.4%) were returned and scored. Image guidance was available to 86% of respondents. Eighteen percent of respondents did not use image guidance in any cases, and 25% used it in up to 10% of cases. Eight percent of respondents used image guidance in >90% of cases. Respondents felt the primary indication for this technology is in revision or advanced cases. Seventy percent of respondents felt image guidance was not typically indicated for a primary total ethmoidectomy and >90% of respondents felt it was either a relative or absolute indication for revision frontal sinus exploration, modified Lothrop procedure, or closure of cerebrospinal fluid leak. Attitudes of the respondents did not vary by year of residency completion or by the use of image guidance during residency. Current access to image guidance was associated with a higher likelihood of feeling it was indicated. Conclusion The majority of respondents had access to image guidance. Many feel it is a relative or absolute indication for revision and advanced endoscopic sinus and skull base procedures. A very small minority used this technology in all cases. The results of this survey reflect the opinion of the respondents. They do not necessarily reflect the views of the American Rhinologic Society or of practicing otolaryngologists in general.

This study was performed to determine the location of the natural ostium of the sphenoid sinus relative to the intact superior turbinate.Forty-seven cadaveric specimens were examined. Mucosa over the sphenoethmoidal recess, superior turbinate, and posterior ethmoid was left intact. The position of the sphenoid sinus natural ostium relative to the superior turbinate was identified.The sphenoid ostium was identified in all specimens. In all specimens, the sphenoid ostium was found to be medial to the intact superior turbinate, notwithstanding lateral deflection of the posterior few millimeters of the superior turbinate in some cases.The superior turbinate is an excellent landmark for the sphenoid sinus natural ostium. Previous observations of the ostium positioned lateral to the superior turbinate may have been caused by stripping of the superior turbinate mucosa before measurements were taken. In the intact specimen, the sphenoid ostium is reliably found medial to the superior turbinate.

Hyaluronan (HA) is a ubiquitous component of the extracellular matrix. HA and its derivatives have been used in the sinuses to reduce scarring and possibly promote wound healing. However, in recent animal studies, HA esters exhibited inflammatory effects. Mitomycin C (MMC) is another potential antiscarring treatment. This study prospectively evaluated the effects of three different HA constructs on wound healing in the rabbit maxillary sinus: (i) a novel cross-linked HA hydrogel, (ii) the cross-linked HA gel containing covalently bound MMC, and (iii) a commercially available woven HA ester (Merogel).Ostia were created with a 4-mm otologic drill in the maxillary sinuses of 15 New Zealand white rabbits with one side randomly chosen for treatment. After 14 or 21 days the size of the maxillary ostia were recorded and the tissue was examined under light microscopy.Sinuses treated with the novel HA and HA-MMC hydrogels showed an increased ostial diameter compared with untreated controls. Woven HA ester-treated sinuses showed no improvement, with a trend toward a smaller ostium than controls. Histological examination showed that woven HA ester tended to cause increased fibrosis and granulomatous inflammation, and heterophilia was slightly increased in the HA hydrogel-treated sinuses. Blinded observation noted foamy macrophages surrounding the residual woven HA ester in each specimen while no similar reaction was noted near the residual HA or HA-MMC hydrogels.This study suggests that the degree of ostial narrowing, inflammation, and fibrosis depends on the formulation of the HA used. Minimal, if any, additional benefit is seen with addition of MMC to the HA hydrogel in this pilot study.

Cerebrospinal fluid (CSF) otorhinorrhea can rarely complicate lateral skull base surgery, necessitating sealing of the eustachian tube. Patulous eustachian tube (pET) can also be an indication for closure of the eustachian tube.Representative cases and the technique will be described.The authors describe a technique used in three cases of CSF otorhinorrhea and one case of pET to successfully close the eustachian tube.Previous reports have described methods of eustachian tube closure utilizing nasal endoscopic techniques. These techniques have relied on packing of the orifice and/or the nasopharynx for successful closure. The authors describe their experience with an alternative technique. The technique does not rely on any packing, which may become dislodged. It has the added advantage of potential reversibility in cases of pET.

Objectives: To compare the distribution patterns of topical medication delivery systems in the sinonasal region and upper respiratory tract after functional endoscopic sinus surgery. Study Design: Prospective descriptive evaluation. Methods: Four topical delivery systems (spray bottle, atomizer, nebulizer, and bulb syringe) were studied. Using a dye solution as a marker, we independently applied the four topical delivery systems to a population of patients with chronic rhinosinusitis who had undergone functional endoscopic sinus surgery. The anatomic distributions were videotaped using flexible fiberoptic endoscopy. Three blinded observers independently rated the anatomic distribution of dye using a 4 point scale. Statistical analysis was performed using analysis of variance (ANOVA) and Dunn posttesting. Results: Seven participants completed the study. All participants had undergone bilateral maxillary antrostomies, bilateral total ethmoidectomies, and bilateral sphenoidotomies. Five sinonasal sites and the larynx were evaluated for dye deposition. Interobserver agreement reached 95.6%. There was no statistical difference between the atomizer and spray bottle. The bulb syringe was statistically superior to the nebulizer in all sinonasal sites and statistically superior to the atomizer and spray bottle in the ethmoidal region. Dye was rarely seen within the larynx. Conclusions: The delivery systems tested were shown to have significant differences in their capability to place dye in specific sinonasal areas. Because topical medications are commonly administered to postoperative patients, these differences may have important clinical implications.

Transsphenoidal microsurgery has been the standard approach to sellar lesions since the repopularization of the technique with modifications by Dott, Guiot, and Hardy. The endonasal transseptal transsphenoidal approach, as introduced by Hirsch, is still commonly used by pituitary surgeons to remove lesions of the sellar and parasellar region. One disadvantage of this approach is that the submucosal dissection requires postoperative nasal packing, which is a source of discomfort in patients who undergo transsphenoidal surgery. The authors describe a novel closure technique for the unilateral endonasal transsphenoidal approach that eliminates the need for full nasal packing, minimizing postoperative rhinological morbidity. This technique has been performed in 67 patients harboring sellar and parasellar lesions. All patients recovered rapidly without significant rhinological sequelae.

We describe a case of invasive fungal sinusitis caused by Scytalidium dimidiatum in a lung transplant recipient. Treatment was complicated by renal failure with amphotericin B therapies. Following 6 months of voriconazole treatment, the patient remained radiographically and clinically stable for a short time before dying of respiratory failure precipitated by graft rejection.

The fate of the middle turbinate in endoscopic sinus surgery has been a subject of debate for some time. The superior turbinate's role, however, has been largely passed over. Past anatomic descriptions and illustrations have given surgeons the incorrect impression that this structure is well superior and out of the field of dissection. Injury to the superior turbinate may account for postoperative hyposmia. The superior turbinate also serves as a constant landmark for the sphenoethmoidal recess, and a limited resection allows the surgeon to identify and include the natural ostium of the sphenoid sinus in the sphenoidotomy. The embryology and anatomy of the superior turbinate are reviewed. An approach to the natural ostium of the sphenoid sinus from the lateral side of the middle turbinate, using the superior turbinate as a guide, is described.

Rhinosinusitis, an inflammatory disease involving the nasal cavity and paranasal sinuses, affects millions of individuals and its costs run into the billions of dollars. The development of rigid nasal telescopes has revolutionized the diagnosis and treatment of this disease. Recent endoscopic evaluations have identified certain key areas within the nasal cavity that, when inflamed, lead to sinus ostial obstruction and subsequent sinus infection. The telescope's increased visualization capabilities permits the physician to better target and individualize patient care and the techniques that have grown out of this new tool allow for a more physiologic approach to surgical treatment. The pathophysiology of rhinosinusitis and its medical treatments are considered. Indications for surgical management are reviewed, with attention to nontraditional or extended applications of endoscopic techniques. Preoperative evaluation, including nasal endoscopy and radiographic imaging, as well as surgical technique and postoperative care are discussed. Evaluation of outcomes from surgical treatment in appropriately selected patients have demonstrated the success of this technique.

Carotid artery (CA) injury after transsphenoidal and endoscopic sinus surgery is a well-recognized but fortunately rare complication.1 It is associated with significant morbidity and mortality rates5 and is more common in cases of repeated surgery, cavernous sinus invasion, prior radiotherapy, and anatomical anomalies of the sphenoid and cavernous sinuses.4 It usually results in CA stenosis, occlusion, or pseudoaneurysm formation followed by serious complications, such as stroke and caroticocavernous fistulas.5 Direct surgical repair is difficult, and treatment may require parent vessel sacrifice and possibly vascular bypass.5 We describe the successful treatment of a cavernous‐CA pseudoaneurysm with a novel CA-sparing approach. This 62-year-old woman with recurrent esthesioneuroblastoma underwent endoscopic tumor resection. A CA injury occurred intraoperatively. Hemostasis was rapidly achieved by packing the bleeding site with cottonoid and packing strip gauze within the sphenoid sinus. Postoperative angiography performed immediately after surgery revealed a 2-mm pseudoaneurysm at the anterior genu of the left cavernous internal CA (ICA) with minimal stenosis (Fig. 1 left). Eight days after the initial arterial injury, repeat angiography demonstrated persistence of the aneurysm. To repair the arterial defect and preserve the CA, an endovascular stent was placed across the puncture site to restore its normal caliber and to provide a buttressing surface for surgical repair by graft apposition (Fig. 1 right). Subsequently, with the aid of the operating microscope, a small piece of autologous fascia lata graft was placed directly over the arterial puncture site via a transnasal‐transsphenoidal approach and bound using BioGlue (CryoLife, Inc., Kennesaw, GA), a two-component (bovine serum albumin and glutaraldehyde) surgical adhesive that is used as an adjunct to open surgical repair of large vessels, such as the aorta, femoral artery, and CA. 2