Lal, Devyani

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.

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.

Background/Objectives: Although endoscopic dacryocystorhinostomy (DCR) has been widely accepted as the procedure of choice for nasolacrimal duct obstruction (NLDO) management due to most etiologies, concerns regarding the reactivation of disease and involvement of surrounding structures add to hesitation in its utilization for granulomatosis with polyangiitis (GPA) patients. No study has directly compared outcomes of external vs. endoscopic DCR in GPA patients. This information can be helpful for patient counselling and choosing a personalized surgical approach for the best results. Methods: A scoping review of the literature was performed in January 2024. The following databases were searched using a combination of MeSH (Medical Subject Headings) and keywords: Ovid MEDLINE, Ovid EMBASE, Scopus, and Web of Science. This scoping review is not registered. Medical records of two GPA patients who underwent endoscopic DCR at our center were reviewed. Results: The search yielded 96 articles; 15 articles met the inclusion criteria for a full review. Six studies with 22 procedures reported 100% success with endoscopic DCR. Nine studies with 122 procedures reported success in 88.5% of cases with external DCRs. Additional perioperative immunosuppression was recommended in patients with severe mucosal inflammation. The case series presents the disease course, details of surgery, and perioperative management in two GPA patients with NLDO who underwent endoscopic DCR successfully. Conclusions: Endoscopic DCR was associated with equivalent or better success rates and lower complications compared to external DCR in GPA patients. Ensuring disease remission state and appropriate immunomodulatory therapy can help prevent the proposed risk of endonasal disease reactivation with endoscopic DCR.

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.

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.

AbstractThe study objective was to compare the length of stay (LOS) and the proportion of one-night admissions before and after the implementation of an endocrine monitoring protocol following endoscopic transsphenoidal surgery (ETSS) for pituitary adenoma.Patients who underwent transsphenoidal pituitary adenoma resection between July 1, 2018, and September 9, 2022, were identified, and divided into two cohorts before and after the implementation of the monitoring protocol. The overall LOS and number of nights of admission were recorded. Readmission within 30 days after surgery was also recorded. The number of outpatient laboratory tests performed and the time to the first test were also noted.Thirty patients were identified in the preprotocol group and 60 in the postprotocol group. The average admission length in the preprotocol group was significantly longer than the average admission length in the postprotocol group (2.4 vs. 1.7 days, p = 0.004). The percentage of one-night admissions increased from 13 to 57% (p < 0.001). There were no significant differences in readmission rates between the two groups (p = 0.681). The number of laboratory encounters increased from a mean of 1.38 to 2.40 (p = 0.030), while the time to the first test decreased from a mean of 3.43 to 2.36 days (p = 0.049).Patients admitted after ETSS for pituitary adenoma had shorter hospital stay and greater proportion of one-night admission with the implementation of an endocrine monitoring protocol. The all-cause readmission rate was not statistically different between the two groups. Through aggressive outpatient laboratory monitoring, one-night admission for ETSS may be feasible.