Marino, Michael J.

ABSTRACTObjectivesSaddle nose deformity (SND) can be associated with nasal septal perforation (NSP). Both SND and NSP are observed in granulomatosis with polyangiitis (GPA) patients. This study aimed to compare the prevalence and severity of SND in GPA vs. non‐GPA patients with NSP.MethodologyNSP patients who visited tertiary rhinology or facial plastic surgery clinics from January 2010 through December 2023 were grouped into GPA and non‐GPA cohorts. The area of NSP, SND incidence, and SND severity (Daniel and Brenner's classification) were compared between the cohorts.ResultsOf 168 patients identified with NSP, 18 had GPA and 150 had non‐GPA diagnoses. Twelve GPA patients and 10 non‐GPA patients had SND. The odds ratio for SND association in GPA patients with NSP vs. non‐GPA patients was 31.3 (95% CI: 9.5–102.9), and 19.4 (95% CI: 4.3–87.7) after controlling for the NSP area. GPA patients with SND had a larger NSP area (median 670 mm2, IQR: 315.5–1061.3) compared to non‐GPA patients with SND (175.3 mm2, 113.1–204.1; p < 0.001). The severity of SND was similar between GPA and the non‐GPA group (p = 0.09). The area of NSP did not predict the severity of SND (p = 0.17).ConclusionGPA diagnosis was associated with larger NSPs and a higher risk of SND compared to non‐GPA etiologies; however, the severity of saddling did not differ between GPA and non‐GPA etiologies. GPA is an independent risk factor associated with SND irrespective of the size of septal perforation. The NSP area did not predict the severity of SND.Level of Evidence: 4.

Objectives/Hypothesis: Botulinum neurotoxin type-A (BoNT-A) injection into the true vocal cords is an effective treatment for restoring vocal functionality in adductor spasmodic dysphonia (AdSD). The Glasgow Benefit Inventory was developed to measure quality of life change following any otolaryngologic intervention and was recently revised to a 5-factor subdomain (GBI-5F) questionnaire to improve clinical utility. The study aim was to utilize the GBI-5F to measure patient-reported quality of life change in AdSD patients following BoNT-A injection. Methods: The GBI-5F questionnaire was administered to patients diagnosed with AdSD who received a BoNT-A vocal cord injection between December 2022 and May 2023. All patients had received multiple prior injections. GBI-5F subdomains and demographics were analyzed to identify areas for patient-reported improvement. Results: Sixty-six patients completed the GBI-5F. There were 52 (78.7%) females and average age was 69.4 years. The median total benefit score was +40.0 (interquartile range [IQR], 20.0). Median subdomain scores were +83.3 (IQR, 50.0) for quality of life, +50.0 (IQR, 50.0) for self-confidence, +33.3 (IQR, 33.3) for social involvement, +16.7 (IQR, 50.0) for support, and 0.0 (IQR, 16.7) for general health. Differences in the individual subdomain scores were statistically significant ( P < .0001). No significant differences were found in the total GBI-5F score or any subdomain according to sex or presence of vocal tremor (all P > .05). A moderately positive correlation was noted between median total score and percent functional improvement (r = 0.46, P < .001). Conclusion: Botulinum injection therapy for AdSD provides overall benefit to patients as measured by the GBI-5F, with particular improvement observed for perceived quality of life, self-confidence, and social involvement. Sex, presence/absence of vocal tremor, and age do not appear to modify benefit, though degree of functional improvement is positively correlated with total score.

AbstractObjectivePrevious studies synthesizing published data on nasal septal perforation (NSP) repair outcomes have cited the lack of standardization in evaluation and data reporting. The heterogeneity of this literature base limits the quality of available evidence and precludes intercomparison. The aim of this study is to quantitatively characterize trends in NSP evaluation and reporting and identify areas for improvement.Data SourcesPubMed, Scopus, and Web of Science.Review MethodsA comprehensive review of the literature published from 2012 through 2024 investigating NSP repair techniques was conducted, and perforation evaluation and outcome reporting were characterized and compared between contemporary and older cohorts.ConclusionsOutcomes of NSP repair are increasingly studied. The heterogeneity of current literature concerning the evaluation of perforations and the reporting of outcomes precludes high‐quality comparative analyses of outcomes across separate studies. This review demonstrated a lack of progress towards greater standardization over the last 12 years. There remains room for improvement in regard to the evaluation and reporting of etiology, defect size, symptomatology, and objective outcome of repair, allowing for adequate duration of follow‐up.Implications for PracticeThere are many inconsistencies in the collection, organization, and analysis of data implicated in investigations of NSP repair outcomes. The development and agreement upon consensus practice guidelines would engender greater standardization among the evaluation and assessment of treatment outcomes. Based on this review and our institutional experiences, we propose specific measures that would facilitate higher‐quality future research and advance the practice of perforation management.

Abstract Reconstruction of clival defects may be challenging in expanded endonasal skull base surgery. We conducted a systematic review to evaluate the outcomes of vascularized flaps used for clival reconstruction. The following databases were searched using a combination of Medical Subject Headings (MeSH) and keywords related to clival reconstruction in July 2024: Ovid Medline, Ovid Embase, Scopus, and Web of Science. Studies reporting outcomes of clival reconstruction with vascularized free and pedicled flaps in patients were selected for complete review. Twenty-three studies were included for detailed study. Clival reconstruction with free flaps was done in 18 patients; 17 had a successful repair, outcome was not reported for 1. Facial vessels were preferred for microvascular anastomosis. Radial artery forearm flap and anterolateral thigh flap were most utilized. Pedicled flaps were used in 68 patients, with reported success in 85.3%. Nasoseptal flap was the most common intranasal flap, used in 34 patients with successful reconstruction in 85.3%. Temporoparietal fascia flap was the most common extranasal flap, successfully used in 13 patients. Intranasal pedicled flaps, wherever available, were preferably used for primary reconstruction; extranasal flaps were the next choice. Free flaps were reserved for salvage reconstruction due to prior failed or unavailable local pedicled flaps. Satisfactory reconstructive outcomes are reported using pedicled and free flaps. The flap of choice is determined by the previous surgical history, radiotherapy, wound vascularity, defect size, overall health of the surrounding nasal mucosa, simultaneous clival surgery, and the preferred pedicle transposition route (free flaps).

ABSTRACTObjectivesTransnasal endoscopic sphenopalatine artery ligation (TESPAL) has been proposed as a first‐line therapy for intractable epistaxis before utilizing posterior nasal packing and embolization. A specific procedure code for TESPAL was newly introduced in 2018, adding to two prior codes for procedural control of epistaxis. This study compares all‐time utilization of the TESPAL CPT code in Medicare beneficiaries with alternative procedural codes for epistaxis management.MethodsThe publicly available data from the Centers for Medicare and Medicaid Services in the 2013–2022 period was analyzed for the reporting of TESPAL (31241), transcatheter permanent occlusion or embolization of noncentral nervous system, head, or neck (61626), and endoscopic control of epistaxis (31238) codes. Welch two sample t‐test and linear regression were used to characterize CPT code utilization.ResultsFrom 2018 to 2022, TESPAL CPT code reporting averaged 378 instances annually, with a stable utilization trend (p = 0.432). CPT codes 61626 and 31238 averaged 1429 and 3779 instances annually, respectively. CPT 31238 showed a significant decline (p < 0.001), and CPT 61626 showed a stable trend (p = 0.082). There was a significant decline in CPT code 31238 use after 2018 (p < 0.01). CPT 61626 showed a significant increase in usage post‐2018 (t = 2.90, p = 0.044).ConclusionAfter an initial increase in 2019, TESPAL reporting flattened, while CPT 61626 (which includes all embolization in head and neck vessels) significantly increased post‐2018. As recent studies show significant advantages of TESPAL over embolization, these findings warrant further attention and study.Level of Evidence3.

Fungal rhinosinusitis (FRS) can be classified into invasive and non-invasive forms, with the fungal ball (FB) representing a common non-invasive type with generally favorable outcomes post-operatively. The clinical presentation of FB can vary and be non-specific, and it is important to consider a wide differential diagnosis for sinonasal masses, including malignancy. We present the case of a 74-year-old female presenting with a two-year history of nasal obstruction and drainage. She has a history of breast cancer and prior maxillomandibular surgery, and imaging showed a poorly defined mass in the right maxillary sinus with possible hemorrhagic and/or proteinaceous content. Rigid nasal endoscopy revealed a friable mass, and endoscopic sinus surgery findings were consistent with FB. This case exemplifies the need to consider a broad set of differential diagnoses when evaluating sinonasal masses, especially if the patient has a prior malignancy or maxillomandibular surgical history, including FB and metastases to the paranasal sinuses. Given the presence of non-specific symptoms, it is important to consider early imaging for patients with distorted anatomy and a history of malignancy. Endoscopic sinus surgery, with high success rates, is the gold-standard treatment for FB.

ABSTRACTBackground/AimEosinophilic granulomatosis with polyangiitis (EGPA) is a multisystemic disease associated with nasal polyposis. Multiple biologics are used for managing EGPA, including some approved for nasal polyps (NP). This study investigated real‐world biologic prescription patterns for EGPA and their impact on NP and endoscopic sinus surgery (ESS) use.MethodsEGPA patients with NP treated with a biologic at any Mayo Clinic site (January 2010 to January 2024) were identified by querying the unified electronic medical record. Patterns of biologic therapy, clinical course, impact on NP, and performance of ESS were studied.ResultsEighty patients were identified. Overall, 71 of 80 (88.75%) patients underwent ESS, with 62 of 80 (77.5%) undergoing 131 ESS procedures prior to biologic therapy. ESS for recalcitrant NP (47 episodes) was performed on 38 of 80 (47.5%) patients on biologics. Biologic monotherapy was used in 90% (72) of patients; mepolizumab (81.9%) was the most common, followed by rituximab (23.6%), benralizumab (18.1%), and dupilumab (12.5%). Switching of biologics was observed in 28 of 80 patients. Concurrent dual‐biologic therapy was used in eight (10%) patients. For patients on single‐agent biologic therapy, ESS was performed on 52.5% of patients on mepolizumab, 23.5% on rituximab, 42.8% on benralizumab, and 22.2% on dupilumab.ConclusionsMultidisciplinary multi‐modality treatment with biologics and ESS appeared to be the mainstay of controlling NP in EGPA. Mepolizumab was the most frequently used biologic. Dual biologic therapy was necessary in 10% of patients. Overall, 71 of 80 (88.75%) patients had ESS, with almost half the study population (47.5%) undergoing ESS after initiating biologic treatment.