Swisher, Austin R.

Inverted sinonasal papilloma (ISP) and respiratory epithelial adenomatoid hamartoma (REAH) are sinonasal lesions with overlapping clinical, radiographic, and histologic features, making accurate diagnosis challenging. ISP is a benign but aggressive tumor with a propensity for local destruction, recurrence, and malignant transformation, whereas REAH is a hamartomatous lesion often arising in the olfactory cleft. We present four patients with lesions initially suspected to be ISP based on intraoperative frozen section but ultimately diagnosed as REAH on permanent pathology. All patients had polypoid sinonasal masses, frequently involving or adjacent to the olfactory cleft. Intraoperative frozen sections were often inconclusive or favored ISP, reflecting the difficulty of distinguishing these entities. Histologic analysis revealed that epithelial thickness served as a key morphologic feature differentiating ISP from REAH, with REAH exhibiting ciliated glandular proliferation and ISP characterized by hyperplastic epithelium with features of columnar and squamous differentiation. These patients underscore the diagnostic pitfalls of small biopsies and frozen sections, and highlight the importance of permanent specimens and collaboration with experienced pathologists. Accurate differentiation is critical, as management strategies differ substantially: ISP requires aggressive resection and long-term surveillance, while REAH may be treated with limited excision and minimal follow-up.

Abstract Objective Intraoperative parathyroid hormone (ioPTH) monitoring is crucial during parathyroid surgery to ensure chemical cure. However, delays in processing can prolong operative times. This study evaluates the effectiveness of a checklist to expedite ioPTH assay processes. Methods A multidisciplinary checklist was developed to standardize ioPTH collection and workflow. Thirty patients treated with use of the checklist were prospectively studied, while 30 patients treated without use of the checklist were retrospectively reviewed. Time intervals for post–15‐minute ioPTH assay results were compared. Results Thirty age‐ and sex‐matched patients were included in each group (n = 60) involving 5 surgeons. The intervention and control group had a mean baseline PTH of 140.9 and 130.3 pg/mL and a post–15‐minute ioPTH of 69.6 and 52.0 pg/mL, respectively. The mean time from sample collection to the post–15‐minute ioPTH assay result was significantly reduced in the intervention as compared to the control group (22.2 vs 33.3 minutes; P < .01). The proportional operative time spent awaiting ioPTH assay results was also reduced (24.4 vs 34.1%; P < .01). In subgroup analysis, a significant difference in the total operative time was found in adenomatous disease (68.0 vs 92.2 minutes, P < .05) but not four‐gland hyperplasia (119.3 vs 142.3 minutes). Discussion The implementation of a simple intraoperative checklist effectively reduces the overall ioPTH assay processing time, creating a more efficient surgical workflow. It is low‐cost and requires minimal additional resources. Implications for Practice This quality improvement intervention holds promise for broader adoption in parathyroid surgery to reduce delays and optimize patient care.

Balloon-assisted dilation (BAD) of paranasal sinus ostia is a Food and Drug Administration (FDA)-approved minimally-invasive procedure used to treat medically refractory chronic rhinosinusitis. Several large cohort studies have reported relatively-low complication rates with BAD. Thus, users of this technology may perceive this to be a safer alternative to formal dissection of the frontal and sphenoid sinus and perform these as office-based procedures. Here, we present 2 patients who underwent BAD of the sphenoid sinus and developed cerebrospinal fluid leak (CSF) leaks with pneumocephalus. Both patients had thinning of the planum sphenoidale in generously-pneumatized sphenoid sinuses. Although BAD is considered safe, review of the current literature demonstrates that serious complications can occur. These case reports demonstrate the potential for skull base injury, particularly in hyper-pneumatized sphenoid sinuses with dehiscent bone. Preoperative anatomic evaluation is crucial to identify at-risk patients. During BAD, trauma to critical structures may cause CSF leak and result in pneumocephalus. This knowledge is important for improving surgical decision-making and patient counseling. Level of Evidence: III.

Abstract Objective To use an artificial intelligence (AI)‐powered large language model (LLM) to improve readability of patient handouts. Study Design Review of online material modified by AI. Setting Academic center. Methods Five handout materials obtained from the American Rhinologic Society (ARS) and the American Academy of Facial Plastic and Reconstructive Surgery websites were assessed using validated readability metrics. The handouts were inputted into OpenAI's ChatGPT‐4 after prompting: “Rewrite the following at a 6th‐grade reading level.” The understandability and actionability of both native and LLM‐revised versions were evaluated using the Patient Education Materials Assessment Tool (PEMAT). Results were compared using Wilcoxon rank‐sum tests. Results The mean readability scores of the standard (ARS, American Academy of Facial Plastic and Reconstructive Surgery) materials corresponded to “difficult,” with reading categories ranging between high school and university grade levels. Conversely, the LLM‐revised handouts had an average seventh‐grade reading level. LLM‐revised handouts had better readability in nearly all metrics tested: Flesch‐Kincaid Reading Ease (70.8 vs 43.9; P < .05), Gunning Fog Score (10.2 vs 14.42; P < .05), Simple Measure of Gobbledygook (9.9 vs 13.1; P < .05), Coleman‐Liau (8.8 vs 12.6; P < .05), and Automated Readability Index (8.2 vs 10.7; P = .06). PEMAT scores were significantly higher in the LLM‐revised handouts for understandability (91 vs 74%; P < .05) with similar actionability (42 vs 34%; P = .15) when compared to the standard materials. Conclusion Patient‐facing handouts can be augmented by ChatGPT with simple prompting to tailor information with improved readability. This study demonstrates the utility of LLMs to aid in rewriting patient handouts and may serve as a tool to help optimize education materials. Level of Evidence Level VI.