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ObjectivePreliminary data have demonstrated long-term efficacy of posterior nasal nerve (PNN) cryoablation in reducing rhinitis symptoms for patients with allergic rhinitis (AR) and nonallergic rhinitis (NAR). We sought to evaluate the impact of procedural cryoablation of the PNN on quality of life (QOL) in patients with AR and NAR.MethodsAdult patients undergoing PNN cryoablation for AR or NAR after appropriate medical therapy were included for analysis. Demographics, medical therapies, baseline rhinitis symptom (total nasal symptom score [TNSS]), and disease-specific QOL (mini-rhinoconjunctivitis quality of life questionnaire [mini-RQLQ]) were recorded. The Wilcoxon signed-rank test was used to test for significant changes in baseline test scores posttreatment. Absolute and relative improvement in outcomes was determined for each participant. Secondary outcomes were assessed with univariate and multivariate analyses.ResultsFourteen patients were enrolled with a mean follow-up of 16.5 weeks. The TNSS and mini-RQLQ scores significantly improved after PNN cryoablation (median δs [interquartile range]: -4 [3] and -1.61 [1.08], respectively; both P = .0002). The minimal clinically important difference for the TNSS and mini-RQLQ was obtained in 92.9% of patients in each category. Relative mean percentage (%) improvement after PNN cryoablation in the TNSS and mini-RQLQ was 40.7% and 40.5% (standard deviation = 24.9 and 29.5, respectively), respectively, for all patients. Patients with NAR (n = 10) reported mean improvement of 41.3% (29.1) as measured by the TNSS and 49.6% (25.9) by mini-RQLQ. Patients with AR reported mean percentage improvement in TNSS and mini-RQLQ scores of 39.5% (12.1) and 24.6% (28.5), respectively. Patients who had been prescribed a nasal anticholinergic for management prior to PNN cryoablation had statistically significantly increased improvement in mini-RQLQ scores from pre- to post-procedure (P = .0387).ConclusionSurgical cryoablation of the PNN significantly improves both symptoms and disease-specific QOL in majority of patients with AR and NAR.

A spontaneous cerebrospinal fluid (CSF) leak occurs when the CSF egresses from the subarachnoid space of teh anterior or middle cranial fossa into the surrounding sinonasal or middle ear cavities through a dehiscence of the lamia dorsa.

Introduction  Comorbid major depressive disorder (MDD) is present in up to 25% of chronic rhinosinusitis (CRS) cases and provides prognostic information for patients undergoing endoscopic sinus surgery (ESS). Clinical visits offer an opportunity to identify at-risk patients. Objective  The purpose of the present study is to evaluate practice patterns among members of the American Rhinologic Society (ARS) in screening for/diagnosing MDD. Methods  A 21-question survey was distributed to 1,206 members of the ARS from May 26, 2018 to June 12, 2018. The impact of demographic factors, including hospital setting, fellowship status, and experience were assessed through chi-squared analysis. Results  A total of 80 members of the ARS completed the survey, yielding a response rate of 7%. Half of the respondents worked in academic settings and 43% had completed a rhinology fellowship. Twenty percent of the participants felt comfortable diagnosing or managing MDD, while only 10% of participants screened for MDD in patients with CRS. Respondents cited a lack of training (76%) and unfamiliarity with diagnostic criteria (76%) as barriers to the routine assessment of MDD. Most respondents (95%) considered comorbid psychiatric illness to negatively impact outcomes following ESS. Fellowship-trained respondents were significantly more likely to implement screening tools in their practice ( p  = 0.05), and believe in the negative impact of MDD on postoperative outcomes ( p  = 0.007), cost of care ( p  = 0.04) and quality of life ( p  = 0.047). Conclusion  Amongst ARS members, 95% of the respondents consider comorbid MDD to negatively impact patient outcomes following ESS. Regardless, a large proportion of surgeons neither screen nor feel comfortable diagnosing MDD.

BackgroundPosterior nasal nerve (PNN) cryoablation is a novel surgical technique to address allergic and nonallergic rhinitis. Periprocedural pain has been reported after PNN cryoablation and there are no standardized protocols for optimal in-office local anesthesia. This study sought to evaluate the effect of gabapentin on patient discomfort following in-office PNN cryoablation.MethodsMulti-institutional prospective analysis of patients undergoing in-office PNN cryoablation for allergic or nonallergic rhinitis between March 2018 and April 2019. Patients received local anesthesia with or without 600 mg oral gabapentin 1 hour preprocedure. Rhinitis diagnosis, demographics, and baseline disease-specific quality of life (mini-Rhinoconjunctivitis Quality of Life Questionnaire [RQLQ] and Total Nasal Symptom Score [TNSS]) were recorded. Patient discomfort was measured by the pain visual analogue scale (VAS) posttreatment and rated 0 to 10 on an ordinal scale. Fisher's exact and Wilcoxon 2-sample tests were used to evaluate differences between the 2 groups.ResultsA total of 26 patients were enrolled (gabapentin n = 15, control = 11). Baseline TNSS scores in the gabapentin vs control group were median [25th percentile to 75th percentile]) 10 (7.5 to 11.0) and 9 (6.0 to 10.0) (p = 0.35). Baseline Mini-RQLQ scores in gabapentin vs control groups were 3.21 (2.0 to 4.0) and 2.92 (2.78 to 4.35) (p = 0.51). The median VAS pain scores at 5, 20, and 30 minutes in the gabapentin vs control group were 0.0 (0.0 to 2.0) vs 3.0 (1.0 to 4.0), 2.0 (0.0 to 3.0) vs 8.0 (6.0 to 10.0), and 1.0 (0.0 to 1.0) vs 5.0 (4.0 to 6.0) (p = 0.02, p = 0.0043, and p = 0.003, respectively).ConclusionPreprocedure gabapentin significantly reduces immediate and delayed postprocedural patient discomfort following PNN cryoablation.

Skull base surgery has evolved significantly since Harvey Cushing‘s first descriptions in the early 1900s. Computer aided surgery (CAS) applications continue to expand; they include virtual surgical planning, augmented and virtual reality, 3D printing of models/cutting guides/implants, surgical navigation, and intraoperative imaging. The authors will review the current skull base CAS literature and propose a computer aided surgical workflow categorizing these applications into 3 phases: 1) Virtual planning, 2) Surgical execution, 3) Intraoperative verification.

Cerebrospinal fluid (CSF) leak occurs from traumatic, iatrogenic, and idiopathic etiologies. Its timely diagnosis requires clinical, radiographic, and laboratory testing. Medical and surgical management can mitigate the risk of life-threatening infection and morbidity. This article outlines the pathophysiology, diagnosis, and management or CSF leak of the anterior skull base.

Objectives/hypothesisWe sought to evaluate preoperative and postoperative productivity losses and quality of life (QOL) impairment reported by patients with recurrent acute rhinosinusitis (RARS) as compared to patients with chronic rhinosinusitis without nasal polyposis (CRSsNP).Study designProspective, multi-institutional, nested case-control.MethodsParticipants with RARS (n = 20) and CRSsNP (n = 20) undergoing endoscopic sinus surgery (ESS) were enrolled as part of a prospective cohort study. For comparison, participants diagnosed with RARS cases were age/gender-matched to control participants diagnosed with CRSsNP using a 1:1 ratio.ResultsRARS and CRSsNP participants were followed for ∼14 months postoperatively. Productivity losses were reported as the number of days missed from normal productive activities out of the previous 90 days. RARS participants reported similar baseline productivity losses (12.6 ± 27.1 [standard deviation]) as participants with CRSsNP (11.7 ± 20.9; P = .314). Postoperatively, improvement in productivity losses was similar between RARS participants and CRSsNP controls (-6.7 ± 20.0 vs. -9.8 ± 19.1; P = .253). Preoperative and postoperative disease-specific QOL measures (Sino-Nasal Outcomes Test-22 and Rhinosinusitis Disability Index) were similar between the two groups. RARS participants reported a significant decrease in days of previous antibiotic (P = .009) and nasal decongestant (P = .004) use following ESS, whereas participants with CRSsNP reported a significant decrease in antibiotic (P = .002) and oral corticosteroid use (P = .002).ConclusionsRARS patients report baseline productivity losses and disease-specific QOL impairment to levels that parallel those with CRSsNP. Patients with RARS report improvement in QOL following ESS in all disease-specific QOL measures and in several medication measures. Productivity losses and postoperative improvements are similar between patients with RARS and CRSsNP.Level of evidence3b Laryngoscope, 126:1046-1053, 2016.

ImportanceIntraoperative computed tomography (CT) provides surgeons with real-time feedback during maxillofacial trauma and reconstructive surgery, which can affect intraoperative decision making.ObjectivesTo evaluate the time needed to perform intraoperative CT scans during maxillofacial surgery, determine any trend toward shorter total scan times as experience is gained with the technique, and identify the characteristics of cases that required intraoperative revision based on the results of intraoperative CT scanning.Design, setting, and participantsA retrospective review was completed for all maxillofacial reconstruction procedures that used intraoperative CT between January 1, 2012, and March 31, 2014.InterventionsPatients were cared for by the routine practice pattern of the authors. Intraoperative CT scans were obtained for all patients.Main outcomes and measuresTime needed for intraoperative CT scan was measured and trends were analyzed. Covariates included age, sex, complexity of fracture, procedure type, total scan time, surgeon, and need for intraoperative revision based on intraoperative CT findings.ResultsThirty-eight cases were identified, including 30 males (79%) and 8 females (21%). The mean (SE) age was 37.4 (16.0) years (range, 7-75 years). Cases were defined as routine (18 [47%]) or complex (20 [53%]). Isolated orbital fractures were the most common fracture (23 [61%]) in both the routine (14 [78%]) and complex (9 [45%]) cases. The mean (SE) total scan time was 14.5 (4.9) minutes (range, 6-27 minutes) and did not differ based on complexity (P = .34). Intraoperative revisions were performed in 9 patients (24%) and were more common in complex (n = 8) than routine (n = 1) cases (P = .004). There was no reduction in total scan time during the study period (P = .22). The mean (SE) scan time for the most experienced surgeon was 3.78 (1.53) minutes shorter than for the other surgeons as a group (P = .02).Conclusions and relevanceCurrent intraoperative CT scanning techniques are rapid, averaging 14.5 minutes per case. No decrease in total scan time was noted during the study; however, the surgeon most experienced with the CT software had the shortest total scan times. Intraoperative revisions were most common in complex cases. We recommend surgeons consider the use of intraoperative CT imaging for maxillofacial reconstruction, particularly in complex procedures.Level of evidenceNA.

Objective: Preliminary data have demonstrated long-term efficacy of posterior nasal nerve (PNN) cryoablation in reducing rhinitis symptoms for patients with allergic rhinitis (AR) and nonallergic rhinitis (NAR). We sought to evaluate the impact of procedural cryoablation of the PNN on quality of life (QOL) in patients with AR and NAR. Methods: Adult patients undergoing PNN cryoablation for AR or NAR after appropriate medical therapy were included for analysis. Demographics, medical therapies, baseline rhinitis symptom (total nasal symptom score [TNSS]), and disease-specific QOL (mini-rhinoconjunctivitis quality of life questionnaire [mini-RQLQ]) were recorded. The Wilcoxon signed-rank test was used to test for significant changes in baseline test scores posttreatment. Absolute and relative improvement in outcomes was determined for each participant. Secondary outcomes were assessed with univariate and multivariate analyses. Results: Fourteen patients were enrolled with a mean follow-up of 16.5 weeks. The TNSS and mini-RQLQ scores significantly improved after PNN cryoablation (median δs [interquartile range]: −4 [3] and −1.61 [1.08], respectively; both P =.0002). The minimal clinically important difference for the TNSS and mini-RQLQ was obtained in 92.9% of patients in each category. Relative mean percentage (%) improvement after PNN cryoablation in the TNSS and mini-RQLQ was 40.7% and 40.5% (standard deviation = 24.9 and 29.5, respectively), respectively, for all patients. Patients with NAR (n = 10) reported mean improvement of 41.3% (29.1) as measured by the TNSS and 49.6% (25.9) by mini-RQLQ. Patients with AR reported mean percentage improvement in TNSS and mini-RQLQ scores of 39.5% (12.1) and 24.6% (28.5), respectively. Patients who had been prescribed a nasal anticholinergic for management prior to PNN cryoablation had statistically significantly increased improvement in mini-RQLQ scores from pre- to post-procedure (P =.0387). Conclusion: Surgical cryoablation of the PNN significantly improves both symptoms and disease-specific QOL in majority of patients with AR and NAR. [ABSTRACT FROM AUTHOR]