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Inferior turbinate reduction procedures have been performed for decades. After significant evolution, turbinoplasty and other mucosal-sparing techniques have become the main method to successfully reduce turbinate hypertrophy. The debate of which technique produces the most effective and durable outcomes is ongoing. During this critical era of widespread communicable diseases, including but not limited to COVID-19, HIV, and hepatitis, additional attention is necessary to balance outcomes with a degree of generation of airborne particles when selecting a technique. This review article aims to identify the optimal method for inferior turbinate reduction that weighs both outcomes and aerosol production. The MEDLINE database was searched to discover relevant publications through August 2022. Key search terms included inferior turbinate hypertrophy, turbinate reduction surgery, turbinoplasty methods, surgical management of turbinate hypertrophy, surgical aerosol generation, COVID-19 surgery, surgery smoke plume, SARS-CoV-2 transmission during surgery, and nasal procedures COVID-19 aerosols. Surgical management of the inferior turbinates includes radiofrequency ablation (RFA), microdebrider-assisted turbinoplasty (MAIT), electrocautery, laser, and ultrasound. Piezo-assisted turbinoplasty and a turbinate-specific coblation wand are new additions to the literature. All techniques appear to improve patient symptoms of nasal obstruction. MAIT and RFA are comparable, although MAIT demonstrated better long-term outcomes in some studies and appears to generate fewer airborne particles. Studies evaluating the production of aerosols due to RFA are lacking. Ultrasound outcomes are also excellent and generate no aerosols, but the technique has not been compared against the microdebrider. Electrocautery can result in increased pain and crusting for patients and causes the highest amount of aerosols. Deficiencies of current studies, including a lack of comparison of aerosol generation, duration of follow-up, omission of outfracture, and inadequate randomized controlled trials among existing and new techniques, have limited the identification of the best inferior turbinate reduction method. Given the durability of MAIT and its minimal aerosol production, it can be reinforced as the most sensible technique until further evidence is available., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Smith et al.)

Objective: To investigate the use of near-infrared (NIR) imaging as a tool for outpatient clinicians to quickly and accurately assess for maxillary sinusitis and to characterize its accuracy compared to computerized tomography (CT) scan., Methods: In a prospective investigational study, NIR and CT images from 65 patients who presented to a tertiary care rhinology clinic were compared to determine the sensitivity and specificity of NIR as an imaging modality., Results: The sensitivity and specificity of NIR imaging in distinguishing normal versus maxillary sinus disease was found to be 90% and 84%, normal versus mild maxillary sinus disease to be 76% and 91%, and mild versus severe maxillary sinus disease to be 96% and 81%, respectively. The average pixel intensity was also calculated and compared to the modified Lund-Mackay scores from CT scans to assess the ability of NIR imaging to stratify the severity of maxillary sinus disease. Average pixel intensity over a region of interest was significantly different ( P < .001) between normal, mild, and severe disease, as well as when comparing normal versus mild ( P < .001, 95% CI 42.22-105.39), normal versus severe ( P < .001, 95% CI 119.43-174.14), and mild versus severe ( P < .001, 95% CI 41.39-104.56) maxillary sinus disease., Conclusion: Based on this data, NIR shows promise as a tool for identifying patients with potential maxillary sinus disease as well as providing information on severity of disease that may guide administration of appropriate treatments.

Background: Studies have suggested that physicians are steadily being paid less per Medicare service over time based on inflation-adjusted dollars. The objective of this study was to determine whether this phenomenon was true for rhinologic procedures., Methods: This study was a retrospective analysis of the 2000-2021 Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule investigating fees for in-office endoscopies (Current Procedural Terminology [CPT] codes 31231-31238), in-office balloon ostial dilation (CPTs 31295-31298), in-facility low-relative value unit (RVU) surgeries (<10 work RVUs [wRVUs]; CPTs 31239-31288 and 61782), and in-facility high-RVU surgeries (>10 wRVUs; CPTs 31290-31294). Total number of and reimbursements for these services was obtained from yearly National Part B Summary Datafiles., Results: Between 2000 and 2021, adjusted reimbursements for low- and high-wRVU rhinologic surgeries decreased by 50.0% and 36.1%, respectively. The average compound annual growth rate (CAGR) decrease was 3.3% and 2.1%, respectively. Excluding a 48.3% unadjusted reimbursement increase between 2000 and 2004, endoscopies saw an adjusted reimbursement decrease of 29.4% from 2004 onward, an average CAGR of -2.1%. From 2011 onward, balloon ostial dilations saw a decrease in adjusted reimbursement of 43.8%, an average CAGR of -6.0%. Nevertheless, after inflation adjustment, National Part B data reveal that Medicare paid more, in total, for these procedures in 2019 than in 2000 due to increasing utilization., Conclusion: Medicare reimbursements are complex, adjusted yearly, and undergo constant federal scrutiny due to the increasing costs of health care. These results suggest that, in terms of real dollars, rhinologic procedures have seen a large gradual decrease in Medicare reimbursement, which is important information for policymakers and surgeons alike., (© 2021 ARS-AAOA, LLC.)

Juvenile nasopharyngeal angiofibroma (JNA) is a locally aggressive tumor that predominantly affects adolescent males. Surgical resection is generally considered the standard treatment for both primary and recurrent tumors, regardless of staging. The natural history of these tumors, particularly when untreated or in the setting of residual tumor, is not well characterized. In this article, we report a case of true spontaneous JNA involution. Although the involution of residual tumor after surgical resection has previously been reported, to our knowledge, this is the first documented case of spontaneous JNA involution following a period of tumor growth post-treatment. Laryngoscope, 131:1455-1457, 2021., (© 2020 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Objectives: To investigate how the decision to report United States Medical Licensing Examination (USMLE) Step 1 score as pass/fail will influence future otolaryngology residency application and match processes., Study Design: Survey study., Methods: An anonymous and voluntary survey approved by the Otolaryngology Program Directors Organization was administered to academic faculty members from April 24, 2020 through May 19, 2020., Results: Two hundred fifty-seven surveys were received from department chairs (17.5%), program directors (24.1%), associate program directors (12.5%), and department faculty (45.9%). USMLE Step 1 has been the most heavily weighted metric for offering interviews (44.0%), and it has correlated with residents' medical knowledge (77.0%) and in-service performance (79.8%) but not with surgical skills (57.6%) or patient care (47.1%). In total, 68.1% disagreed with the decision to make USMLE Step 1 pass/fail. This change is anticipated to lead to an increase in significance of USMLE Step 2 CK (89.1%), core clerkship grades (80.9%), elective rotation at the respective institutions (65.7%), Alpha Omega Alpha and other awards (64.6%), and letters of recommendation (63.8%). The new scoring is also anticipated to especially benefit students from top-ranked schools (70.8%), increase medical students' anxiety/uncertainty regarding obtaining interview invites (59.1%), and negatively affect international (51.4%), doctor of osteopathic medicine (45.9%), and underrepresented students (36.9%). Indication that USMLE Step 2 CK will significantly increase in weight varied according to department position (P = .049), geographic region (P = .047), years of practice (P < .001), and residency program size (P = .002)., Conclusion: Most academic otolaryngologists disagreed with changing USMLE Step 1 scoring to pass/fail and believe that it will increase other objective/subjective metrics' weight and put certain student populations at a disadvantage., Level of Evidence: N/A. Laryngoscope, 131:E738-E743, 2021., (© 2020 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Objectives: Budesonide nasal irrigation is currently widely used in the treatment of chronic sinusitis typically following endoscopic sinus surgery to improve inflammatory control. Its application in treatment of allergic rhinitis has not been previously studied. This study assesses the subjective and clinical response to budesonide buffered hypertonic saline nasal irrigation and hypertonic saline nasal irrigation in patients with allergic rhinitis., Study Design: This is a prospective, single-center, double-blind, randomized placebo-controlled trial., Setting: Tertiary care hospital., Subjects and Methods: Fifty-two patients diagnosed with allergic rhinitis were randomized into 2 groups to receive either buffered hypertonic saline nasal irrigation with a placebo respule or buffered hypertonic saline nasal irrigation with a budesonide respule. Patients were assessed at baseline and 4 weeks subjectively using the Sino-Nasal Outcome Test-22 (SNOT-22) questionnaire and visual analog scale (VAS). Clinical assessment was done using the modified Lund-Kennedy score., Results: The average SNOT-22, VAS, and modified Lund-Kennedy scores improved in both groups ( P < .001). The budesonide irrigation group was found to have significantly better improvement than the saline nasal irrigation group with the SNOT-22 scores ( P = .012) and VAS scores ( P = .007). However, the difference in the clinical response between the 2 groups was not significant ( P = .268)., Conclusion: This study adds evidence to the use of saline nasal irrigation in allergic rhinitis but also demonstrates efficacy of the addition of budesonide to irrigations. Budesonide nasal irrigation thus appears to be a viable treatment option for allergic rhinitis.

We sought to evaluate the usefulness of a monthly telelecture educational series in facial plastic and reconstructive surgery for resident education and to identify potential areas for improvement. A monthly series of facial plastic and reconstructive surgery telelectures were hosted at our institution between 2016 and 2018. A web-based survey was sent to 13 residents and 7 invited faculty presenters. Resident survey questions included rating of presentation topics, interface, networking opportunities, and educational value. Faculty survey questions included satisfaction, temporal convenience, likelihood of future telelecture participation, and likelihood of telelecture series implementation at speaker's home institution. The survey response rate was 100%. All of the residents expressed satisfaction with topics presented, lecture duration, perceived enhancement of education, and overall satisfaction with the telelecture series. 46% of residents indicated that the telelecture format limited networking opportunities. 72% of faculty reported they would participate in a future telelecture, and 86% indicated interest in integrating telelectures into their home institution educational curriculum. Live virtual telelectures effectively allow experienced facial plastic surgeons to share their operative techniques and management pearls in an interactive and practical format. This is a contemporary solution to bridging knowledge gaps between expert facial plastic surgeons from all corners of the world and the next generation of surgeons., Competing Interests: None., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Pituitary apoplexy (PA) is defined by hemorrhage and necrosis of the pituitary gland, often acute in onset, and frequently in the setting of an existing pituitary adenoma. Our objective was to conduct a meta-analysis of the available literature on vision outcomes following surgical intervention for PA on the basis of the timing from apoplexy to surgery (ATS)., Methods: A thorough literature search of the published English-language literature was performed in PubMed, Ovid, and Cochrane databases using the key words ("pituitary apoplexy") and ("surgery" or "vision") from database inception to August 2018 was conducted. The primary outcome variable evaluated using a binary random-effects model was vision recovery outcomes (metric: odds ratio)., Results: Of 234 articles found, 12 articles containing 200 patients met our eligibility criteria. The mean age was 46.1, with a male-to-female ratio of 2.9:1. A total of 86% of PA patients presented with visual deficits (ATS <7 days in 93 and >7 days in 79 patients). In patients with an ATS <7 days, 97.8% experienced visual recovery, compared with 84.8% with an ATS >7 days (odds ratio 2.6 [95% CI 0.94-7.31]; P value = 0.07)., Conclusions: Despite readily accepted guidelines provided by the United Kingdom advocating for early surgical intervention in PA, the rates of vision outcomes we report demonstrate >80% recovery for patients in both the early and late surgical intervention group. As such, conservative management may be warranted for early stabilization before surgical intervention in PA patients with respect to vision outcomes., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives/hypothesis: To describe rates of complications and mortality within 30 days of open anterior skull base surgery using a large, multi-institutional outcomes database., Study Design: Retrospective cohort study., Methods: The study included patients who underwent open anterior skull base surgery as listed in the American College of Surgeons National Surgical Quality Improvement Project database from 2007 through 2014., Results: A total of 336 open anterior skull base surgeries were identified. One hundred nine (32.4%) patients experienced a complication, reoperation, or mortality. The most common events were postoperative transfusion (15.8%), reoperation (10.1%), and readmission (8.0%). Significant independent predictors of any adverse event included higher American Society of Anesthesiologists (ASA) score and increased total operative time (both P < .05). The only predictor of mortality was higher ASA score (P = .02). Predictors of increased hospital stay included impaired sensorium (P = .04), coma >24 hours (P < .001), lower preoperative hematocrit (P = .02), higher ASA score (P = .04), and increased total operative time (P < .001)., Conclusions: Open anterior skull base surgery is understandably complex, and is thus associated with a relatively high adverse event rate. Knowledge of factors associated with adverse events has the potential to improve preoperative optimization of controllable variables and translate into improved surgical outcomes for patients., Level of Evidence: NA Laryngoscope, 129:1407-1412, 2019., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Importance: Postoperative packing in nasal surgery often results in nasal obstruction and discomfort. Commercially available silicone intranasal airways (IAs) serve as dual-nasal airway tubes aimed at alleviating this process, but the safety and efficacy of these devices are unknown., Objective: To evaluate the safety and efficacy of an intraoperatively placed IA device in rhinoplasty and nasal surgery., Design, Setting, and Participants: In this retrospective record review, the medical records of patients undergoing nasal surgery with insertion of the IA at a single institution from 2012 to 2017 were reviewed. After review of over 200 patients, a questionnaire was developed to assess device efficacy., Exposures: Use of the IA device. The IA is 12 cm long, anchored across the columella, extends distally along the nasal floor, and has a proximal external portion used for cleaning and maintaining patency. Placed intraoperatively, the device aims to support air flow postoperatively in the face of edema, hemorrhage, and packing., Results: A total of 302 operations in 300 patients were analyzed, including primary and revision septorhinoplasty. A total of 24 (7.9%) patients self-removed or inadvertently dislodged the IA. Minor acute postoperative complications not unique to airway insertion included cellulitis in 4 (1.3%) participants and epistaxis in 6 (2%). Postoperatively, 1 (0.3%) patient developed dehiscence along transcolumellar incisions. A total of 59 patients (100% compliance) completed the efficacy questionnaire. The mean breathing score was between good and average (2.9 of 5), comfort scores between comfortable and average (2.9 of 5), and mean ease of irrigation score was between very easy and easy (1.96 of 5). The device was irrigated on average 3.57 times per day. A total of 43 (76%) particpiants had full patency or only partial obstruction, compared with 13 (24%) patients with total obstruction. In all patients, with or without obstruction, the effect lasted an average of 4 days., Conclusions and Relevance: The device is safe and well-tolerated for maintaining patency of the nasal airway in patients undergoing rhinoplasty and nasal reconstruction without increased risk of incisional dehiscence., Level of Evidence: 4.

Objective A subset of patients with sinonasal disease who obtain a diagnostic computed tomography (CT) sinus scan may require repeat preoperative CT due to the inadequacy of diagnostic CT for image-guided sinus surgery (IGSS). This leads to increased CT utilization, health care costs, and patient exposure to ionizing radiation. The objective of this study is to determine the frequencies of diagnostic CT sinus studies that were inadequate for IGSS and repeat CT studies for purposes of IGSS. Study Design A retrospective chart study was performed between May 2012 and August 2013. Setting Tertiary care rhinology practice. Subjects and Methods New patients with any sinonasal diagnosis who presented with CT sinus scans acquired from outside institutions were included. CT scans were considered inadequate for IGSS for any of the following reasons: >1.5-mm slice thickness, oblique axial planes due to gantry tilt, and incompletely defined or missing IGSS anatomic landmarks. Results Of 183 patients, 85 (46%) presented with diagnostic CT sinus scans that were inadequate for IGSS. Seventy-one patients met indications for IGSS, of which 37 (52%) required repeat CT due to an IGSS-inadequate diagnostic scan. Conclusion The frequency of repeat preoperative CT sinus imaging may be high at tertiary care centers where IGSS is performed. A standardized IGSS-adequate CT sinus protocol may avoid the need for repeat preoperative scans. Potential advantages include improved efficiency, decreased health care costs, and reduced ionizing radiation exposure to the patient.

Computed tomography (CT) is the current gold standard imaging for chronic rhinosinusitis (CRS) but is limited by cost, risk of radiation, and difficulty of being performed in the typical outpatient primary care setting. We describe the novel use of a low-cost, handheld technology to deliver an intraoral near-infrared (NIR) wavelength light to optically image the maxillary sinuses. Digital images were collected for subjects presenting with sinus disease using an intraoral NIR light source for transillumination of the maxillary sinuses, captured by a modified digital single-lens reflex camera. Light intensity contrasts were enhanced using computer analysis and subsequently compared to CT findings. NIR illumination produced unique patterns reflecting different disease states: normal sinus anatomy, mild sinus disease and/or mucosal thickening, and complete opacification of the sinus. Current results suggest that NIR imaging may facilitate the diagnosis of sinusitis in the outpatient setting with minimal cost and no radiation exposure., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.)

Background: We sought to examine the trends in rates and demographics of ambulatory endoscopic and open sinus surgery for chronic sinusitis over a 7-year period in the state of California., Methods: Patient records with Current Procedural Terminology (CPT) codes for endoscopic or open sinus surgery, and diagnosis codes for chronic rhinosinusitis were extracted from the California Ambulatory Surgery Datasets from 2005 to 2011. Population-adjusted surgery rates were calculated as the number of surgeries per 100,000 California residents. Location of surgery was analyzed in 2 contexts: freestanding ambulatory surgery centers (ASCs) vs any hospital setting, and academic (university medical centers) vs nonacademic centers (ASCs and non-university hospitals combined). Patients' demographics were also examined., Results: A total of 91,984 sinus surgeries were performed during 2005 to 2011. The overall population-adjusted surgery rate declined 24%, from 38.9 to 29.6 (p = 0.004). Although the rates for both endoscopic and open surgeries declined, the percentage of endoscopic procedures increased from 87.3% to 92.5% of all surgeries (p = 0.002). Over the studied period, there was an increase in the proportion of sinus surgeries performed in hospitals (73.2% to 91.3%; p = 0.01), in academic centers (5.9% to 10.1%; p = <0.001), on patients >65 years (14.7% to 17.8%; p = 0.003), and on non-Caucasians (10.3% to 16.9%; p < 0.001). Gender distribution remained unchanged (51% male; p = 0.25)., Conclusion: The overall rate of ambulatory sinus surgery in California declined over the study period. A shift from open to endoscopic procedures, from ASCs to hospitals, and from nonacademic to academic centers was observed. Further investigation of the observed trends may be warranted., (© 2014 ARS-AAOA, LLC.)

Objectives/hypothesis: To identify the prevalence and management of problematic residents. Additionally, we hope to identify the factors associated with successful remediation of unsuccessful otolaryngology residents., Study Design: Self-reported Internet and paper-based survey., Methods: An anonymous survey was distributed to 152 current and former program directors (PDs) in 2012. The factors associated with unsuccessful otolaryngology residents and those associated with the successful remediation of problematic residents were investigated. An unsuccessful resident is defined as one who quit or was removed from the program for any reason, or one whose actions resulted in criminal action or citation against their medical license after graduation from residency. Remediation is defined as an individualized program implemented to correct documented weaknesses., Results: The overall response rate was 26% (40 PDs). Seventy-three unsuccessful or problematic residents were identified. Sixty-six problematic or unsuccessful residents were identified during residency, with 58 of 66 (88%) undergoing remediation. Thirty-one (47%) residents did not graduate. The most commonly identified factors of an unsuccessful resident were: change in specialty (21.5%), interpersonal and communication skills with health professionals (13.9%), and clinical judgment (10.1%). Characteristics of those residents who underwent successful remediation include: poor performance on in-training examination (17%, P < .01) and inefficient use of time (11.4%, P = .02)., Conclusions: A large proportion of otolaryngology PDs in this sample identified at least one unsuccessful resident. Improved methods of applicant screening may assist in optimizing otolaryngology resident selection., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Purpose of Review: To review and discuss recent literature regarding the use of antibiotics in relation to endoscopic sinus surgery (ESS), including perioperative antibiotics, postoperative antibiotics, and antibiotic usage in the setting of postoperative packing., Recent Findings: Perioperative antibiotics are not recommended by the American Society of Health-System Pharmacists. The necessity of antibiotics following ESS is a heavily debated topic. Most studies show little to no improvement in outcomes. Significant improvement in quality-of-life outcomes and endoscopic scoring appears limited to the early postoperative period using conventional postoperative antibiotics. Prolonged macrolide therapy may improve long-term outcomes. There is no convincing evidence to show the need for antibiotics in the setting of postoperative packing., Summary: The available evidence regarding antibiotic use in relation to ESS overall fails to demonstrate routine benefit; however, the studies have various limitations. Overall, future, well designed, large-scale prospective studies would be beneficial to direct appropriate antibiotic use, whether systemic or topical, in relation to ESS.

Background: Potassium-titanyl-phosphate (KTP) laser photocoagulation is commonly used for treatment of hereditary hemorrhagic telangiectasia-related epistaxis (HHT-RE). Electrosurgical plasma coagulation (EPC), also known as coblation, has not been rigorously evaluated for HHT-RE., Methods: Patients seeking treatment for HHT-RE between September 2010 and September 2012 were prospectively randomized (1:1) to KTP or EPC in a single blind prospective cohort study. Length of surgery and estimated blood loss (EBL) were recorded. Epistaxis severity scores (ESSs) and 10-cm visual analogue scale (VAS) scores for HHT-RE-related symptoms were administered at enrollment and at 3, 6, 12 months following surgery. Statistical analysis used Friedman's and Pearson's chi-square tests., Results: Eleven HHT patients were prospectively enrolled and followed. Six patients underwent EPC treatment while 5 underwent KTP. Three patients in the KTP subgroup and 2 patients in the EPC subgroup requested additional surgical treatment within 12 months (p > 0.999). There were no significant differences in terms of EBL (p = 0.126) and length of surgery (p = 0.429) between treatment groups. Mean ESSs were not significantly different between groups at any follow-up point (KTP, p = 0.896; EPC, p = 0.159). Compared to KTP, mean ESSs were higher in the EPC subgroup at baseline and lower at all other time points. Mean nasal obstruction VAS scores were significantly lower in the EPC subgroup at all follow-up points., Conclusion: EPC is a viable alternative to KTP laser photocoagulation for epistaxis control in patients with HHT. Subjectively, patients experience less nasal obstruction following EPC as compared to KTP treatment. A multicentered, well-powered study is warranted to better determine treatment outcomes., (© 2014 ARS-AAOA, LLC.)

Background: Juvenile nasopharyngeal angiofibroma (JNA) is the most common benign neoplasm of the nasopharynx. Almost always unilateral on diagnosis, JNAs are locally invasive and may extend across the midline, giving a false bilateral appearance; as such, true bilateral JNA is exceedingly rare. We present a recent case of true bilateral JNA., Methods: Single case report of a patient with bilateral JNA, including clinical presentation, diagnosis, and management., Results: The patient presented with unilateral nasal obstruction and recurrent epistaxis. Computed tomography and magnetic resonance imaging demonstrated bilateral, noncontiguous masses. Angiography revealed independent vascular supplies from each respective side with no bilateral supply noted. The patient underwent preoperative embolization followed by endoscopic surgical removal of the larger mass; no complications were noted. Follow-up at 2 years demonstrated no recurrence or growth., Conclusion: The vast majority of JNAs are unilateral, though invasive growth to the contralateral side may appear "bilateral" in presentation. Proper identification of true bilateral JNA is helpful in guiding management, wherein excision of both tumors may not be necessary., (© 2014 ARS-AAOA, LLC.)

Background: The role of osteitis, or inflammation involving bone, is 1 potential reason for disease recalcitrance in chronic rhinosinusitis (CRS) and is not extensively studied. This review article will discuss osteitis in CRS, including pathophysiology, diagnostic methods, clinical significance, and treatment modalities., Methods: A systematic review of the literature was performed using PubMed search terms osteitis, osteomyelitis, bone involvement, hyperostosis, neo-osteogenesis, osteoneogenesis, remodeling, single positron emission computed tomography (SPECT), and nuclear scintigraphy, with each term cross-referenced with chronic rhinosinusitis. This search was then narrowed to English language articles, which were reviewed for relevance. Cited references of relevant articles were also examined., Results: The PubMed search identified 231 articles, which after reviewing for inclusion criteria resulted in 26 articles that were included in the current review. Pathophysiology, including current understanding of molecular mechanisms contributing to osteitis, is discussed. Histology, computed tomography (CT), and SPECT have been used to establish a diagnosis. Radiographic staging systems exist but are not standardized. Osteitis has been treated both with intravenous antibiotics and surgery. Five articles involved assessment of outcomes in patients with osteitis., Conclusion: Osteitis involves inflammatory changes in the underlying bone that may lead to recalcitrant CRS. Osteitis is associated with worsened measures of disease severity such as CT, endoscopy, and olfactory scores, and affects the degree of improvement in quality-of-life measures after both medical and surgical treatment. Future studies directed at characterizing the underlying molecular mechanisms including earlier and precise identification may improve our ability to treat this significant aspect of CRS., (© 2013 ARS-AAOA, LLC.)

Background: The significance of osteitis in the management of recalcitrant chronic rhinosinusitis (CRS) has yet to be clearly understood and clinical outcomes data for these patients is lacking. Osteitis has been characterized by inflammatory infiltrate, osteoneogenesis, and bony sclerosis with remodeling. In this study we sought to determine if osteitis negatively impacts quality-of-life (QOL) or clinical outcomes following endoscopic sinus surgery (ESS)., Methods: A total of 190 adult patients with CRS were prospectively enrolled.Osteitis was characterized by quantifiable bony thickening on sinus computed tomography (CT). Baseline measures and postoperative outcomes were evaluated using endoscopy exam, olfactory testing, and 2 validated disease-specific QOL surveys: the Chronic Sinusitis Survey (CSS) and Rhinosinusitis Disability Index (RSDI). Bivariate and multivariate analyses were performed to evaluate differences between patients with and without osteitis., Results: Patients with osteitis (n = 79) had higher prevalence of nasal polyposis and prior ESS (both p < 0.001) and significantly worse baseline CT, endoscopy, and olfactory scores (all p < 0.001) than patients without osteitis. There was no difference in baseline QOL scores between patients with and without osteitis. Following ESS, there were significant improvements in all QOL measures in both groups; however, patients without osteitis were more likely to exhibit clinically meaningful improvement on physical RSDI subscale scores, independent of other clinical factors (79.0% vs 62.3%; odds ratio [OR]: 3.85, p = 0.011)., Conclusion: Osteitis is associated with worse baseline measures of disease severity and inflammation. Our data suggest that whereas patients with osteitis improve after ESS, the presence of osteitis is associated with a reduced chance of improvement in some outcome measures.

Background: Antibiotics are a mainstay of treatment for chronic rhinosinusitis (CRS) and recurrent acute rhinosinusitis(RARS). Although quality-of-life outcomes following endoscopic sinus surgery (ESS) have been studied, the change in antibiotic utilization following ESS is less wellknown., Objective: We aimed to determine the effect of ESS on antibiotic utilization in CRS and RARS., Methods: A multi-institutional, prospective cohort of patients with CRS and RARS was enrolled between January 2001 and January 2009. Patients completed the medication subscale of the Chronic Sinusitis Survey (CSS), and the Wilcoxon signed-rank test was used to compare differences in the overall reported time of antibiotic between preoperative and postoperative time points., Results: A total of 503 patients were followed for an average 17.3 months. Overall, patients reported a 57.2% reduction in time on antibiotics following ESS. The majority of patients (60.4%) reported significantly less antibiotic utilization after ESS (p < 0.001) consisting of an 83.7% reduction in the time on antibiotics. Subgroup analysis also revealed a significant reduction in antibiotic utilization for patients with and without nasal polyposis (59.0% and 58.2%; both p < 0.001) as well as RARS (61.2%; p = 0.001)., Conclusion: ESS significantly reduces antibiotic utilization for CRS and RARS. This finding demonstrates potential for lower health care expenditures related to antibiotics, as well as reduced risk of both antibiotic related morbidity and development of bacterial resistance.

Objectives/hypothesis: To report a novel approach toward revision frontal sinusotomy using a technique of balloon dilation followed by the use of powered instrumentation., Study Design: Case report., Methods: The frontal sinus outflow tract location was first confirmed with image guidance and then dilated with a balloon to address the soft tissue stenosis. Subsequently, the drill was introduced to accomplish a Draf 2B frontal sinusotomy., Results: An advantage of initial balloon dilation of the frontal sinus outflow tract was to quickly address the soft tissue stenosis with minimal tissue trauma and therefore less bleeding. This subsequently enabled insertion and clear visualization of the entire drill bit within the inferior aspect of the frontal outflow tract. The increased visualization makes other instrumentation safer as well, and avoids relatively blind removal of scar tissue that could result in inadvertent entry into the orbit or skull base., Conclusions: We describe the utility of the balloon as a tool for revision frontal sinusotomy to efficiently and safely allow subsequent instrumentation of the frontal outflow tract with larger more aggressive instruments, such as the drill. We have found this to be a safe and effective technique provided proper preoperative patient selection and assessment for limiting factors.

Objectives: We evaluated the presence and pattern of ProEx C stain, a marker for the proliferative capacity of cells, in laryngeal tissues, including benign, malignant, and recurrent respiratory papilloma (RRP) specimens, and compared it to hematoxylin and eosin staining for the presence of dysplasia., Methods: We performed a retrospective study with chart review., Results: A total of 26 specimens (9 benign, 7 malignant, 10 RRP) representing 21 patients were stained. ProEx C stained positive in the nuclei of laryngeal tissue, consistent with its localization in cervical cytology specimens. Seven of 9 benign and 7 of 10 RRP specimens stained positive. The benign specimens were mostly polyps. The malignant specimens were either well or moderately differentiated squamous cell carcinoma, and they stained strongly and diffusely. In benign and RRP specimens, the basal layer typically stained positive. Other areas of epithelium stained weakly in benign specimens and variably in RRP specimens. Current analysis of hematoxylin and eosin-stained RRP specimens revealed that 30% of specimens had at least moderate dysplasia and 80% exhibited viral changes (koilocytosis)., Conclusions: ProEx C is a clean and reliable stain in laryngeal tissue, and stains positive in RRP. This study could not definitively correlate positive ProEx C staining in areas of greater dysplasia, although a trend was observed. Further studies are necessary to determine whether ProEx C can be used in triage of cases of clinically aggressive RRP for closer follow-up or frequent operative intervention.

Objective: To quantify the prevalence and the impact of synchronous airway lesions identified by endoscopy in infants undergoing supraglottoplasty for severe laryngomalacia (LM)., Design: Retrospective study., Setting: Tertiary care pediatric hospital., Patients: Sixty patients who underwent supraglottoplasty for severe LM from 2002 to 2006. Patients who underwent preoperative tracheotomy, had previous airway surgery, or did not have 6 months of follow-up were excluded. Fifty-two patients met inclusion criteria., Intervention: Supraglottoplasty (with carbon dioxide laser)., Main Outcome Measures: Presence of synchronous airway lesions and their contribution to upper airway obstruction (UAO) and their effect on the postoperative course after supraglottoplasty., Results: Fifty-eight percent of patients had synchronous airway lesions (SALs), of whom 77% had subglottic stenosis (SGS) and 47% had tracheomalacia, bronchomalacia, or both. Sixty-three percent of all patients required postoperative nonsurgical airway support. Eight patients had residual UAO requiring additional surgical intervention, with 3 revision supraglottoplasties and 7 tracheotomies performed. Infants with neurological conditions had a high rate of surgical intervention (55%; P = .001). Patients with SGS exceeding 35% but without any neurological condition had a prolonged hospital stay (>3.6 days; P = .02) and an 83% incidence (P = .04) of postoperative UAO requiring intubation. Infants with LM with laryngeal edema (LE) alone had increased frequency of postoperative nonsurgical airway support (P = .02) and a prolonged hospital stay of 1 day (P = .01) compared with infants without edema., Conclusions: There is a high incidence of SALs in patients undergoing supraglottoplasty. Neurological conditions, hypoplastic mandible, SGS greater than 35%, and preexisting LE independently adversely affected the postoperative course.

Objectives: The aim of the study was to report a recent case of mucoepidermoid carcinoma (MEC) of the thyroid, review the pertinent literature, and highlight the importance of multimodal treatment in this potentially aggressive malignancy., Study Design: The study comprise a case report and a review of literature., Methods: A 42-year-old woman had initially presented to another hospital with a painful left neck mass. She subsequently underwent left hemithyroidectomy. Surgical pathology was significant for lymphocytic thyroiditis and MEC. One month later, she presented to us with a right neck mass., Results: The patient underwent completion thyroidectomy and selective neck dissection, including level 6, for high-grade MEC. Operative findings included 3 lymph nodes positive for metastasis and tumor invasion of the transverse cervical vein. Postoperative chemoradiation therapy was administered in 2 cycles separated by 1 month. The patient remains disease-free 22 months after the last treatment., Conclusion: Mucoepidermoid carcinoma is a rare malignancy of the thyroid with less than 35 cases reported to date. The origins of this tumor are not completely understood, with debate regarding whether it arises from solid cell nests of the ultimobranchial apparatus or from follicular epithelium. Although MEC of the thyroid has frequently been reported as low grade, the aggressive presentation in our patient suggests the appropriateness of multimodal therapy.

Tumor lysis syndrome is an oncologic emergency that is characterized by severe electrolyte abnormalities and, frequently, by acute renal failure. The syndrome typically occurs in patients with lymphoproliferative malignancies, most often after initiation of treatment. The pathophysiology involves massive tumor cell lysis resulting in the release of large amounts of potassium, phosphate, and uric acid. Deposition of uric acid and calcium phosphate crystals in the renal tubules may lead to acute renal failure, which is often exacerbated by concomitant intravascular volume depletion. The kidney normally excretes these products, and consequently preexisting renal failure exacerbates the metabolic derangements of tumor lysis syndrome. Standard treatment aims to clear high plasma levels of potassium, uric acid, and phosphorus; correct acidosis; and prevent acute renal failure by way of aggressive intravenous hydration; lowering serum potassium levels; use of allopurinol; urinary alkalinization; or renal replacement therapy (if necessary). Allopurinol is the standard of care for treating hyperuricemia of malignancy, but is associated with drawbacks. Recombinant urate oxidase (rasburicase), which recently became available in the United States, provides a safe and effective alternative to allopurinol for lowering uric acid levels and preventing uric acid nephropathy.