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Background and Objective This study aims to evaluate the medicolegal trends related to 2 common orbital surgeries: orbital decompression and dacryocystorhinostomy (DCR). These procedures are performed by ophthalmologists, otolaryngologists, and multidisciplinary teams of both specialists. Methods The Westlaw database was reviewed from 1980 to 2020 for medical malpractice cases involving orbital decompression and DCR surgeries. Data were compiled on plaintiff and defendant demographics, procedure performed, legal allegation, nature of injury, and verdict or settlement awards. The Ophthalmic Mutual Insurance Company was also queried for all malpractice cases pertaining to orbital decompression and DCR from 1995 to 2021. Results The Westlaw database included 60 cases (34 orbital decompression, 26 DCR); of these, 8 orbital decompression and 6 DCR cases met inclusion criteria. Of the 7 orbital decompression cases that were tried, a verdict in favor of the plaintiff occurred in 4 cases (57%). Of the 5 DCR cases that were tried, a verdict in favor of the plaintiff occurred in 2 cases (40%). A search of all claims at OMIC yielded 31 cases (15 orbital decompression, 16 DCR). 22 of 31 cases were either dismissed or resulted in no payment. The remainder was settled out of court, with only one case being tried and the verdict supporting the defendant. Conclusion Despite several thousand orbital decompressions and DCR surgeries being performed annually in the US, very few lawsuits involving these complex surgeries have gone to trial. However, of the cases that did go to trial, a relatively high proportion of verdicts for plaintiffs was observed.

Background: Diabetes Mellitus (DM) and its associated immune dysfunction are well-studied risk factors for adverse surgical outcomes. The literature regarding endoscopic sinus surgery (ESS) is less robust and there have been conflicting reports on post-operative complications and surgical results in this patient population. The purpose of this study was to analyze the impact of diabetes mellitus on outcomes after ESS via rates of post-operative medical intervention in the first 6 months after surgery. Methods: This was a retrospective cohort study of 176 subjects who underwent ESS from 2015 to 2019 at a single institution by 2 fellowship-trained rhinologists. Subjects were divided into 2 groups, those with a documented Hemoglobin A1c (HbA1c) >6.5 or diagnosis of DM and those with HbA1C Results: Out of n = 176 total patients, n = 39 (22.2%) were categorized into the DM group, which were older (46.4 vs 53.8 years, P = .004) and higher proportion of white patients (89.7% vs 68.6%, P = .008). There were no significant differences between the 2 groups in proportion of revision surgery, surgical extent, and post-operative use of antibiotics or steroids. When including all variables in binary logistic regression for use of postoperative antibiotics or steroids, the only significant variable predicting these outcomes was the extent of surgical resection including sphenoid sinus ( P = .001, OR [95% CI] = 4.02 [1.73-9.34]) or frontal sinus ( P Conclusions: Patients with DM do not appear to have worse post-operative outcomes outside of the initial 6-month postoperative period.

Background: Nasal septal perforations (NSP) cause a variety of bothersome symptoms for patients, and when medical management fails, surgical repair is indicated. Objective: This study examines the efficacy of a NSP repair method utilizing superficial or deep temporal fascia and a polydiaxonone (PDS) plate scaffold to the prior repair method of a pedicled anterior ethmoid mucosal flap. Methods: A retrospective review of patients who underwent NSP repair at a tertiary academic medical center from 2016-2021. Results: The most common etiologies for NSP were prior nasal surgery, digital trauma, and chronic epistaxis. Compared to the previous repair group with local flaps, the temporalis fascia and PDS plate group had significantly higher rates of complete closure for perforations of all sizes and a lower incidence of revision surgery. Patients also reported improved resolution of symptoms after repair with this new method. Conclusion: The use of temporalis fascia with a PDS plate is a promising surgical method for repair of NSP, regardless of size or etiology. Keywords: septal perforation, polydiaxonone, temporalis

Background: Sphenoid and frontal sinuses have narrow ostia and are prone to stenosis. However, their relative rates of patency are not well established, and descriptive rates of sphenoid stenosis have never been reported. The objective is to measure the patency of the sphenoid and frontal sinus ostia postoperatively. Methods: A prospective multi-institutional cohort study was performed. Ostial patency was measured at surgery and 3 and 6 months postoperatively. Pertinent clinical history such as the presence of nasal polyps and prior history of ESS as well as the use of steroid eluting stents were recorded. Overall stenosis rates were calculated for both the sphenoid and frontal sinuses, and Wilcoxon-Signed Rank Test was used to compare intraoperative and postoperative ostial areas. Factorial Analysis of Variance (ANOVA) was performed to determine effects of 5 clinical factors. Results: Fifty patients were included. The mean sphenoid sinus ostial area decreased 42.2% in size from baseline to 3 months postoperatively (T0 55.2 ± 28.7 mm vs T3 m 31.8 ± 25.5 mm, P Conclusion: Both sphenoid and frontal sinus ostia routinely narrow postoperatively, predominately from baseline to 3 months. These findings can serve as a reference for both clinical outcomes and future studies of these surgeries.

OBJECTIVES Cerebrospinal fluid (CSF) leaks and meningoencephaloceles originating in the lateral recess of the sphenoid sinus can be challenging. The traditional transpterygoid approach through the pterygopalatine fossa (PPF) is time consuming and places important structures at risk, which can lead to significant morbidity. We report a multi-institutional experience using a simplified, endoscopic modified transpterygoid approach (MTPA), which spares the PPF contents in the management of lateral sphenoid sinus meningoencephaloceles and CSF leaks. STUDY DESIGN Multi-Institutional, Retrospective Case Series. METHODS Patients with lateral sphenoid recess CSF leaks and meningoencephaloceles between 2014 and 2020 who underwent the MTPA at two academic medical centers were identified. Repair techniques and outcomes were evaluated. RESULTS Thirty-three patients underwent the MTPA for management. Skull base reconstruction was performed using a free mucosal graft (24/33, 72.7%), nasoseptal flap (4/33, 12.1%), bone grafts (3/33, 9.1%), and abdominal fat grafts (2/33, 6.1%). Lumbar drains and perioperative intracranial pressure measurements were routinely employed. Postoperative complications were uncommon and included three patients (9.7%) with temporary V2 anesthesia, one patient (3.2%) with prolonged V2 anesthesia, and one patient (3.2%) with subjective dry eye, all of which resolved at 9 months postoperatively. There were no recurrent CSF leaks resulting in a 100% success rate. Average follow-up was 13 months. CONCLUSION The MTPA reduces morbidity and greatly simplifies access to the lateral sphenoid sinus for the management of CSF leaks and meningoencephaloceles, without compromising exposure. This technique avoids the need for extensive PPF dissection and should be considered for the management of benign lesions involving the lateral sphenoid sinus. LEVEL OF EVIDENCE 4 Laryngoscope, 131:2224-2230, 2021.

Objective: To compare the patient experience of a virtual otolaryngology clinic visit to an in-person visit, especially with its significantly increased implementation during the COVID-19 pandemic. Methods: Patient satisfaction (PS) metrics from the Clinician and Group Consumer Assessment of Healthcare Providers and Systems survey were queried from March 1, 2020 to May 1, 2020 for telehealth visits and January 1, 2020 to March 1, 2020 for in-person visits. Overlapping and comparable questions were analyzed using Mann-Whitney U test, Chi-square test for independence, and Student’s t-test. Results: There were 1284 partial or complete PS surveys from in-person visits and 221 partial or complete virtual PS surveys. There were statistically significantly worse virtual visit evaluations of provider listening, conveyance of information, likelihood to recommend, and overall provider ratings compared to in-person visits. Conclusion: Telehealth has become the new norm for most healthcare providers in the United States. This study demonstrates some of the initial shortcomings of telehealth in an otolaryngology practice and identifies challenges with interpersonal communication that may need to be addressed as telehealth becomes increasingly prevalent. Level of Evidence: 3.

OBJECTIVES/HYPOTHESIS Patients with spontaneous cerebrospinal fluid leaks (sCSF-L) of the temporal bone have isolated calvarial and skull base thinning that is independent of obesity. This study determines if anterior skull base (ASB) sCSF-L patients also have calvarial thinning. STUDY DESIGN Retrospective Cohort Study. METHODS This was a retrospective cohort study of ASB sCSF-L patients compared to nonobese (body mass index [BMI]

Background RARS is a challenging clinical phenomenon that affects many patients, and diagnostic criteria for this condition are not fully characterized in the literature. Objective To examine diagnostic criteria for recurrent acute rhinosinusitis (RARS). Study Design Systematic review. Methods Cochrane, PubMed (MEDLINE), clinicaltrials.gov, EMBASE, Google Scholar, and Web of Science databases were queried for articles related to RARS dating from 1990 to present, according to PRISMA statement guidelines. Full text articles pertinent to the diagnostic criteria of RARS were included in this review. Inclusion criteria included articles specifically addressing RARS; studies with 3 or more patients; and articles in English. Results A total of 1022 titles/abstracts potentially related to RARS were identified. Of these, sixty-nine full texts were selected for review, and 22 of these ultimately met inclusion criteria. The level of evidence was generally low. Studies and guidelines have used many different definitions for RARS diagnosis over the years based on symptomatology, physical examination, nasal endoscopy, imaging, and laboratory domains. Clinically important RARS has been defined most commonly as 4 or more discrete episodes of ARS per year, but this frequency is typically based on expert opinion. Additionally, radiologic anatomic associations such as concha bullosa, accessory maxillary os, and narrowed infundibular distance may be associated with RARS. Endoscopic visualization and imaging are sometimes used to confirm the presence of sinus disease during exacerbations of RARS, but there is variability in this practice. Conclusion The diagnostic definition for RARS has developed over time and is currently based on low level 4 and 5 evidence. Because of the migratory definition of RARS, comparing inter-study results of RARS management remains difficult, and future studies should aim to follow current expert guidelines on diagnostic criteria of RARS.

Objective After significant restrictions initially due to the COVID-19 pandemic, otolaryngologists have begun resuming normal clinical practice. However, the risk of SARS-CoV-2 transmission to health care workers through aerosolization and airborne transmission during rhinologic surgery remains incompletely characterized. The objective of this study was to quantify the number concentrations of aerosols generated during rhinologic surgery with and without interventions involving 3 passive suction devices. Study Design Cadaver simulation. Setting Dedicated surgical laboratory. Subjects and Methods In a simulation of rhinologic procedures with and without different passive suction interventions, the concentrations of generated aerosols in the particle size range of 0.30 to 10.0 µm were quantified with an optical particle sizer. Results Functional endoscopic sinus surgery with and without microdebrider, high-speed powered drilling, use of an ultrasonic aspirator, and electrocautery all produced statistically significant increases in concentrations of aerosols of various sizes (P < .05). Powered drilling, ultrasonic aspirator, and electrocautery generated the highest concentration of aerosols, predominantly submicroparticles

To provide a state of the art review of intranasal antiviral drug delivery and to discuss current applications, adverse reactions, and future considerations in the management of coronavirus disease 2019 (COVID-19).PubMed, Embase, and Clinicaltrials.gov search engines.A structured search of the current literature was performed of dates up to and including April 2020. Search terms were queried as related to topics of antiviral agents and intranasal applications. A series of video conferences was convened among experts in otolaryngology, infectious diseases, public health, pharmacology, and virology to review the literature and discuss relevant findings.Intranasal drug delivery for antiviral agents has been studied for many years. Several agents have broad-spectrum antiviral activity, but they still require human safety and efficacy trials prior to implementation. Intranasal drug delivery has potential relevance for future clinical trials in the settings of disease spread prevention and treatment of SARS-CoV-2 and other viral diseases.Intranasal drug delivery represents an important area of research for COVID-19 and other viral diseases. The consideration of any potential adverse reactions is paramount.

Background Patients are increasingly turning to the internet for health education. Due to the complex pathophysiology, clinic-diagnostic profile, and management spectrum of pituitary tumors, an evaluation of the readability of printed online education materials (POEMs) regarding this entity is warranted. Objective (1) To apply established readability assessment tools to internet search results on the topic of pituitary tumors. (2) To identify sources of complexity in order to guide the creation POEMs that are in line with the reading level of the target audience. Methodology: After independent, neutral internet search for the phrase “pituitary tumor,” the first 100 results were subjected to inclusion criteria matching. Analysis was performed using 5 readability assessment tools including Flesch Reading Ease (FRE), Flesch–Kincaid Grade Level (FKGL), Gunning-Fog Score (GFS), Coleman–Liau Index (CLI), and Simple Measure of Gobbledygook (SMOG). Results A total of 82 websites met inclusion criteria. All websites were found to be at a higher reading level ( P Conclusion There is a significant misalignment between the reading level of patients and the readability of pituitary tumor POEMs. This may lead patients to misconceive their diagnoses, management options, and prognosis.

Objective The primary mode of viral transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is thought to occur through the spread of respiratory droplets. The objective of this study was to investigate droplet and splatter patterns resulting from common endoscopic endonasal procedures. Study Design Cadaver simulation series. Setting Dedicated surgical laboratory. Subjects and Methods After instilling cadaver head specimens (n = 2) with fluorescein solution, endoscopic endonasal procedures were systematically performed to evaluate the quantity, size, and distance of droplets and splatter following each experimental condition. Results There were no observable fluorescein droplets or splatter noted in the measured surgical field in any direction after nasal endoscopy, septoplasty with microdebrider-assisted turbinoplasty, cold-steel functional endoscopic sinus surgery (FESS), and all experimental conditions using an ultrasonic aspirator. Limited droplet spread was noted with microdebrider FESS (2 droplets

Objective To systematically review and analyze clinical, diagnostic, and management trends in sellar and parasellar brown tumors reported in existing literature. Methods In this systematic review, PubMed, Ovid MEDLINE, Scopus, and Google Scholar databases were searched for reported cases of sellar/parasellar brown tumors. Relevant titles and abstracts were screened in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol. Articles meeting inclusion criteria were subjected to data extraction, summarization, and analysis. A rare case of parasellar brown tumor was also presented. Results Eight reports (including the current report) were eligible for inclusion. Mean patient age was 42.75 years. Reported symptoms included visual disturbances (n = 6), headache (n = 5), fatigue (n = 3), nausea/vomiting (n = 2), chest pain (n = 1), neck pain (n = 1), and dysphagia (n = 1). In cases where computed tomography findings were provided (n = 6), lesions were noted to be expansile and lytic. Lesions were hyperintense on T2-weighted magnetic resonance imaging (66.7%) and demonstrated contrast enhancement (83.3%). Histology unanimously showed multinucleated giant cells in a fibrovascular connective tissue stroma. Dramatic symptom resolution was noted in all patients who underwent resection of the sellar/parasellar brown tumor (n = 4; 50%). Conclusions Sellar/parasellar brown tumors are a rare, tertiary manifestation of hyperparathyroidism and can be elusive to diagnose. Diagnosis requires a high index of clinical suspicion in addition to comprehensive biochemical testing, imaging, and histopathologic analysis. Surgical extirpation is favored in cases where the lesion is causing compressive symptoms, or if it is unresponsive to management of hyperparathyroidism.

Purpose There are a variety of implant materials available for orbital floor fracture repair. Implant selection is guided by surgeon experience, availability, and patient specific needs. The purpose of this study is to describe a “wraparound” technique for nylon foil implant placement for large, isolated floor fractures that provides excellent results with low incidence of enophthalmos or other complications. Materials and methods A retrospective chart review from 2012 to 2020 was conducted in patients who underwent isolated orbital floor fracture repair with the use of the “wraparound” nylon foil implant. The surgical technique is described. Preoperative CT scans were assessed, and the patients were divided into groups based on the size of the floor fracture. Postoperative data was collected including Hertel measurements and complications related to the implant. Results There were eighty patients who underwent orbital floor fracture repair with the described technique and had adequate follow-up. There were 18 (22.5%) small-sized fractures, 32 (40%) medium-sized fractures, and 30 (37.5%) large-sized fractures in the study group. One patient (3.33%) in the large fracture group had clinically significant enophthalmos of 2 mm postoperatively. There were no other patients with clinically significant enophthalmos. There were no instances of any complications related to the implant, and no patients required implant removal. Conclusions The “wraparound” technique for a nylon foil implant provides excellent results for isolated orbital floor fractures. It provides more support and stability than traditional nylon implants for larger fractures and has minimal complication rates.

With the largest viral loads in both symptomatic and asymptomatic patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) present in the oral and nasal cavities, agents that act on these two areas have the potential for large therapeutic and prophylactic benefit. A literature review was conducted to elucidate the possible agents useful in treatment of SARS-CoV-2. These agents were evaluated for their current applications, adverse reactions, their current state of study, and any future considerations in their management of coronavirus disease 2019 (COVID-2019). Our review has found that, while there are many promising agents with proven efficacy in their in-vitro efficacy against SARS-CoV-2, more clinical trials and in-vivo studies, as well as safety trials, must be conducted before these agents can be effectively implemented.

Background: Anosmia and hyposmia significantly affect patients’ quality of life and have many etiologies, including trauma, inflammatory conditions including chronic rhinosinusitis, neoplasm, and viral infections, such as rhinovirus and SARS-CoV-2. Objective: Our purpose was to establish whether a consensus exists regarding optimal management of olfactory dysfunction and to provide insight into the treatment of anosmia in the current climate of increased prevalence secondary to COVID-19. Thus, we aimed to systematically review the literature on the management of non-Chronic-rhinosinusitis- related anosmia/hyposmia. Methods: PubMed, EMBASE, and Cochrane databases were searched for articles published since January 1990 using terms combined with Medical Subject Headings (MeSH). We included articles evaluating management of anosmia and hyposmia written in the English language, with original data, a minimum of 3 months of follow-up except for COVID-related studies, at least 2 patients, and well-defined and measurable outcomes. Results: A total of 3013 unique titles were returned upon the initial search. Of these, 297 abstracts were examined, yielding 19 full texts meeting inclusion criteria (8 with level 1 evidence, 3 with level 2, 1 with level 3, and 7 with level 4). The studies included a total of 1522 subjects, with follow up ranging from 3 to 72 months, with an exception for COVID related studies. Endpoints were based on clinically significant improvements of olfactory functions as measured through validated smell tests. Treatments with the most robust data were intranasal corticosteroids and olfactory training. Conclusion: The literature on the treatment of anosmia and hyposmia includes randomized trials showing the efficacy of a few modalities. While further research is needed to expand therapeutic options for this debilitating condition, the current literature supports the use of olfactory training and topical corticosteroids.

Background Giant cell tumors (GCTs) are a locally aggressive primary bone neoplasm of osteoclast-like cells. These lesions largely occur in the epiphyses of long bones, but there have been rare reports of occurrence in the pelvis, spine, or skull. Of those located in the skull, involvement of the clivus has been rarely reported. Case Description We present a case of an 18-year-old woman presenting with a third nerve palsy, found to have a lytic lesion of the upper clivus that was primarily treated with endoscopic endonasal resection. Her third nerve palsy resolved postoperatively, and subsequent histopathologic analysis revealed a GCT. Six-month postoperative magnetic resonance imaging (MRI) revealed progression of residual disease for which she was treated with adjuvant denosumab. This treatment resulted in a significant decrease in the tumor size. She subsequently underwent proton beam radiation. At 1-year postsurgery, the patient's MRI remained stable after completing denosumab and proton therapy. She was neurologically intact and had no issues from her treatment. Conclusions Denosumab has demonstrated anti-GCT efficacy. In combination with proton therapy, it has the potential to spare a young, vulnerable population from adverse long-term effects of traditional adjuvant radiation therapy. To our knowledge, this is the first report of the use of denosumab in the treatment of GCT of the clivus in the United States.

Background Objective Study Design RARS is a challenging clinical problem that impacts many patients. This article seeks to systematically review the literature on RARS management. Methods Cochrane, PubMed, EMBASE, and other databases were queried for articles related to RARS dating from 1990 to present, according to PRISMA guidelines. Inclusion criteria included articles specifically addressing RARS management; studies with 3 or more patients; and articles in English. Results A total of 1022 titles/abstracts potentially related to RARS were identified. Of these, sixty-nine full texts were selected for review, and 10 met inclusion criteria (five with level 4 evidence, four with level 3 evidence, one with level 2 evidence). The studies included a total of 890 patients (Age range 5.8 to 53.5 years), with follow up ranging from 1 to 19 months. Endpoints were primarily based on symptomatic improvement, although some articles also reported post-treatment endoscopic and radiographic findings. Management options included medical therapy (intranasal steroids, antibiotics, nasal saline irrigations, N-acetylcysteine, allergy treatment, and decongestants), balloon sinus dilation (BSD), and endoscopic sinus surgery (ESS). Surgical patients (BSD and ESS) had a trend towards greater symptom control than medically-treated patients, but meta-analysis was not possible. Conclusion Despite increasing interest in the treatment of RARS, there remains a lack of consensus regarding optimal management. The literature thus far, largely based on expert opinion, suggests that surgical management, either through balloon sinus dilation or endoscopic sinus surgery, may be helpful in improving symptoms and quality of life in those who do not respond to initial trials of medical management.

The risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission to health care workers during myringotomy and tympanostomy tube (MT) insertion is unknown. To determine the need for enhanced precautions to prevent potential spread via aerosolized particles, we used an optical particle sizer to measure aerosol generation intraoperatively during a case series of MT insertion. We also discuss our institutional experience with safe pandemic-era perioperative practices. There was no measured increase in aerosol particle number during the procedure at a distance of 30 cm from the external auditory canal. These initial data are reassuring regarding the risk of SARS-CoV-2 transmission to the operating room team due to aerosol generation, but further study is necessary before making definitive recommendations.

Objective Cadaveric simulations have shown endonasal drilling and cautery generate aerosols, which is a significant concern for otolaryngologists during the COVID‐19 era. This study quantifies aerosol generation during routine rhinologic surgeries and in‐office procedures in live patients. Methods Aerosols ranging from 0.30 to 10.0 μm were measured in real‐time using an optical particle sizer during surgeries and in‐office procedures. Various mask conditions were tested during rigid nasal endoscopy (RNE) and postoperative debridement (POD). Results Higher aerosol concentrations (AC) ranging from 2.69 to 10.0 μm were measured during RNE (n = 9) with no mask vs two mask conditions (P = .002 and P = .017). Mean AC (0.30‐10.0 μm) were significantly higher during POD (n = 9) for no mask vs a mask covering the patient's mouth condition (mean difference = 0.16 ± 0.03 particles/cm3, 95% CI 0.10‐0.22, P

Assessing speech discrimination skills in individual infants from clinical populations (e.g., infants with hearing impairment) has important diagnostic value. However, most infant speech discrimination paradigms have been designed to test group effects rather than individual differences. Other procedures suffer from high attrition rates. In this study, we developed 4 variants of the Visual Habituation Procedure (VHP) and assessed their robustness in detecting individual 9-month-old infants' ability to discriminate highly contrastive nonwords. In each variant, infants were first habituated to audiovisual repetitions of a nonword (seepug) before entering the test phase. The test phase in Experiment 1 (extended variant) consisted of 7 old trials (seepug) and 7 novel trials (boodup) in alternating order. In Experiment 2, we tested 3 novel variants that incorporated methodological features of other behavioral paradigms. For the oddity variant, only 4 novel trials and 10 old trials were used. The stimulus alternation variant was identical to the extended variant except that novel trials were replaced with "alternating" trials-trials that contained repetitions of both the old and novel nonwords. The hybrid variant incorporated elements from both the oddity and the stimulus alternation variants. The hybrid variant proved to be the most successful in detecting statistically significant discrimination in individual infants (8 out of 10), suggesting that both the oddity and the stimulus alternation features contribute to providing a robust methodology for assessing discrimination in individual infants. In Experiment 3, we found that the hybrid variant had good test-retest reliability. Implications of these results for future infant speech perception work with clinical populations are discussed.

Background Real-time polymerase chain reaction using nasopharyngeal swabs is currently the most widely used diagnostic test for SARS-CoV-2 detection. However, false negatives and the sensitivity of this mode of testing have posed challenges in the accurate estimation of the prevalence of SARS-CoV-2 infection rates. Objective The purpose of this study was to evaluate whether technical and, therefore, correctable errors were being made with regard to nasopharyngeal swab procedures. Methods We searched a web-based video database (YouTube) for videos demonstrating SARS-CoV-2 nasopharyngeal swab tests, posted from January 1 to May 15, 2020. Videos were rated by 3 blinded rhinologists for accuracy of swab angle and depth. The overall score for swab angle and swab depth for each nasopharyngeal swab demonstration video was determined based on the majority score with agreement between at least 2 of the 3 reviewers. We then comparatively evaluated video data collected from YouTube videos demonstrating the correct nasopharyngeal swab technique with data from videos demonstrating an incorrect nasopharyngeal swab technique. Multiple linear regression analysis with statistical significance set at P=.05 was performed to determine video data variables associated with the correct nasopharyngeal swab technique. Results In all, 126 videos met the study inclusion and exclusion criteria. Of these, 52.3% (66/126) of all videos demonstrated the correct swab angle, and 46% (58/126) of the videos demonstrated an appropriate swab depth. Moreover, 45.2% (57/126) of the videos demonstrated both correct nasopharyngeal swab angle and appropriate depth, whereas 46.8% (59/126) of the videos demonstrated both incorrect nasopharyngeal swab angle and inappropriate depth. Videos with correct nasopharyngeal swab technique were associated with the swab operators identifying themselves as a medical professional or as an Ear, Nose, Throat–related medical professional. We also found an association between correct nasopharyngeal swab techniques and recency of video publication date (relative to May 15, 2020). Conclusions Our findings show that over half of the videos documenting the nasopharyngeal swab test showed an incorrect technique, which could elevate false-negative test rates. Therefore, greater attention needs to be provided toward educating frontline health care workers who routinely perform nasopharyngeal swab procedures.

With the largest viral loads in both symptomatic and asymptomatic patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) present in the oral and nasal cavities, agents that act on these two areas have the potential for large therapeutic and prophylactic benefit. A literature review was conducted to elucidate the possible agents useful in treatment of SARS-CoV-2. These agents were evaluated for their current applications, adverse reactions, their current state of study, and any future considerations in their management of coronavirus disease 2019 (COVID-2019). Our review has found that, while there are many promising agents with proven efficacy in their in-vitro efficacy against SARS-CoV-2, more clinical trials and in-vivo studies, as well as safety trials, must be conducted before these agents can be effectively implemented.

Purpose The COVID-19 pandemic has led to concerns over transmission risk from healthcare procedures, especially when operating in the head and neck such as during surgical repair of facial fractures. This study aims to quantify aerosol and droplet generation from mandibular and midface open fixation and measure mitigation of airborne particles by a smoke evacuating electrocautery hand piece. Materials and methods The soft tissue of the bilateral mandible and midface of two fresh frozen cadaveric specimens was infiltrated using a 0.1% fluorescein solution. Surgical fixation via oral vestibular approach was performed on each of these sites. Droplet splatter on the surgeon's chest, facemask, and up to 198.12 cm (6.5 ft) away from each surgical site was measured against a blue background under ultraviolet-A (UV-A) light. Aerosol generation was measured using an optical particle sizer. Results No visible droplet contamination was observed for any trials of mandible or midface fixation. Total aerosolized particle counts from 0.300–10.000 μm were increased compared to baseline following each use of standard electrocautery (n = 4, p

Background Anosmia and hyposmia have many etiologies, including trauma, chronic sinusitis, neoplasms, and respiratory viral infections such as rhinovirus and SARS-CoV-2. We aimed to systematically review the literature on the diagnostic evaluation of anosmia/hyposmia. Methods PubMed, EMBASE, and Cochrane databases were searched for articles published since January 1990 using terms combined with Medical Subject Headings (MeSH). We included articles evaluating diagnostic modalities for anosmia, written in the English language, used original data, and had two or more patients. Results A total of 2065 unique titles were returned upon the initial search. Of these, 226 abstracts were examined, yielding 27 full-text articles meeting inclusion criteria (Level of evidence ranging from 1 to 4; most level 2). The studies included a total of 13,577 patients. The most utilized diagnostic tools were orthonasal smell tests (such as the Sniffin’ Sticks and the UPSIT, along with validated abridged smell tests). Though various imaging modalities (including MRI and CT) were frequently mentioned in the workup of olfactory dysfunction, routine imaging was not used to primarily diagnose smell loss. Conclusion The literature includes several studies on validity and reliability for various smell tests in diagnosing anosmia. Along with a thorough history and physical, validated orthonasal smell tests should be part of the workup of the patient with suspected olfactory dysfunction. The most widely studied modality was MRI, but criteria for the timing and sequence of imaging modalities was heterogenous.

Purpose Diplopia and ocular motility restriction following orbital fracture repair are common complications. The reported rates in the literature differ greatly, in part due to varying definitions of diplopia and methods of measurement. The purpose of this study is to describe a practical and efficient in-office method for examining ocular motility and diplopia in orbital trauma patients and to report the outcomes in a series of patients who underwent orbital floor fracture repair. Materials and methods A retrospective chart review from 2012 to 2019 was conducted in patients who underwent isolated orbital floor fracture repair within 3 weeks of trauma. All patients had examinations to assess extraocular motility and subjective diplopia using the described techniques. Results Ninety-three patients underwent orbital floor fracture repair and had adequate follow-up. Preoperatively, 71 (76%) patients had some restriction in motility and 59 (63%) patients complained of diplopia. Postoperatively, only 1 patient (1.09%) had clinically significant diplopia. Five (5.4%) additional patients demonstrated mild restriction in supraduction upon detailed ophthalmic examination that was not discovered upon subjective history. No patients had worsening of diplopia or motility after surgery. Conclusions Diplopia and motility restriction following orbital fracture repair can be a persistent problem for some patients. It is important to perform a careful ophthalmic examination to detect motility deficits and diplopia that can be significant to the patient. The true rate of restriction and diplopia may be higher using detailed ophthalmic diagnostic techniques compared to subjective patient history.

Objective The risk of SARS‐CoV‐2 transmission to healthcare workers through airborne aerosolization during otologic surgery has not been characterized. The objective of this study was to describe and quantify the aerosol generation during common otologic procedures in both cadaveric surgical simulation and live patient surgery. Methods The number concentrations of generated aerosols in the particle size range of 0.30 to 10.0 μm were quantified using an optical particle sizer during both a cadaveric simulation of routine otologic procedures as well as cochlear implant surgery on live patients in the operating room. Results In the cadaveric simulation, temporalis fascia graft harvest using cold techniques (without electrocautery) (n = 4) did not generate aerosols above baseline concentrations. Tympanoplasty (n = 3) and mastoidectomy (n = 3) both produced statistically significant increases in concentrations of aerosols (P, In this cadaveric simulation study, temporalis fascia graft harvest without electrocautery did not generate aerosol levels above baseline, while significant aerosol levels were generated during mastoidectomy and to a much less degree during tympanoplasty. Aerosol spikes were appreciated during cochlear implant surgery in live patients.

Background First described in the early 1990s, endoscopic orbital decompression has become increasingly popular and has been shown to be a safe and effective approach for surgical decompression of the medial and inferior orbit. Methods We present our preferred technique for performing an endoscopic orbital decompression, highlighting key pearls and pitfalls. Results An endoscopic wide maxillary antrostomy and sphenoethmoidectomy is performed in standard fashion. We prefer to resect the middle turbinate for optimal exposure and access. The medial orbital wall is skeletonized and the lamina papyracea is carefully elevated, preserving the underlying periorbita. The orbital floor medial to the infraorbital nerve is resected. Once the periorbita is fully exposed, parallel axial incisions along the medial orbit and orbital floor are made from posterior to anterior using a sickle knife, taking care not to bury the tip to avoid injuring underlying orbital contents. The remaining fibrous bands are incised and prolapse of orbital fat is observed. Post extubation bag mask ventilation is limited to avoid subcutaneous emphysema. Conclusion Compared to open techniques, endoscopic orbital decompression provides superior visualization of critical anatomical landmarks, assures healthy sinus functioning post procedure, offers a lower complication rate, and avoids external incisions.

Background: Internal carotid artery (ICA) injuries represent a rare, potentially fatal complication of endoscopic endonasal skull base surgery (EESBS). The use of adenosine to induce transient hypotension and facilitate management of high-flow, high-pressure arterial lesions has been well-documented in neuro-endovascular literature. A similar setting in which adenosine-induced hypotension may prove beneficial is during the management of major vascular injury encountered during EESBS. Methods: A case of ICA injury and subsequent repair during EESBS is presented. Results: A 74-year-old female underwent endoscopic transsphenoidal resection for a recurrent pituitary adenoma. During suprasellar resection, the right cavernous ICA was inadvertently injured resulting in brisk bleeding. Immediate vascular tamponade was applied, and a crushed muscle graft was obtained. Two intravenous doses of adenosine were administered in quick succession to produce transient hypotension and facilitate repair of the injury with the graft. Neurovascular imaging revealed a small pseudoaneurysm which remained stable throughout the postoperative course. The patient underwent definitive stent embolization of the pseudoaneurysm 1 month following discharge. Conclusion: Prompt repair of ICA injury during EESBS is crucial, but often limited by poor visualization. Adenosine-induced hypotension has demonstrated great efficacy as an adjuvant in neurovascular clipping of intracranial aneurysms and remains a valuable tool for the endoscopic skull-base surgeon as well. In cases with high risk for ICA injury, adenosine should be readily available.

To provide data on risk of respiratory droplets from common otolaryngologic procedures during the COVID-19 pandemic, a novel simulation of droplet exposure from flexible laryngoscopy was performed. After completion of a nasal symptom questionnaire, topical fluorescein spray was administered into the nasal and oropharynx of 10 healthy volunteers, who then underwent flexible laryngoscopy under 2 conditions: routine without provoked response and with prompted sneeze/cough. After each, droplets on the proceduralist and participant were counted under ultraviolet A light. Droplets were observed on 1 of 10 volunteers after routine laryngoscopy and 4 of 10 during laryngoscopy with sneeze/cough. A nasal symptom score based on congestion and rhinorrhea was significantly elevated among droplet producers after sneeze/cough (P = .0164). No droplets were observed on the provider. Overall, with adequate personal protective equipment, flexible laryngoscopy poses minimal droplet risk to providers. Nasal symptoms can identify patients more likely to produce droplets after sneeze/cough.

As the coronavirus disease 2019 (COVID-19) pandemic continues to evolve through the United States and other countries, differing rates of progression and decline are occurring based on varied population densities. While some health systems are reaching a steady state of new patient cases, others are seeing a leveling off or decline, allowing for restoration of normal practices. This "reverse-surge" planning and implementation process is a colossal undertaking for health systems trying to reacquire patient access and financial stability while preserving necessary resources and maintaining precautions for another potential surge. For the otolaryngologist, reverse-surge planning involves additional workflow adjustments in the outpatient and operating room settings given the abundance of COVID-19 virus in the upper aerodigestive tract. As the reverse-surge best practices are still under development, open communication between otolaryngology colleagues and health system leadership is paramount to optimize efficiency and maintain an adequate measure of safety for patients and our health care teams.