Choby, Garret

Background Selecting the optimal surgical approach for resection of sinonasal inverted papilloma (SIP) remains a challenge, with endoscopic, external, and combined approaches being utilized. This systematic review was conducted as an update to a 2006 systematic review to determine the preferred surgical approach for tumor control. Methods The study protocol was developed a priori following the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) process. Data were collected and outcomes were analyzed according to surgical approach and sites of tumor involvement. Results A total of 96 papers and 4134 SIP patients were included. The overall recurrence rate was 12.80% (322/2515) for the endoscopic approach group, 16.58% (182/1098) for the external approach group, and 12.60% (65/516) for the combined approach group. Meta‐analysis by random effects model showed that the summarized risk ratio (RR) of recurrence was 0.61 (95% confidence interval [CI], 0.44 to 0.85, p = 0.003), I 2 = 37.95% for the endoscopic vs external approach; 0.98 (95% CI, 0.69 to 1.39, p = 0.901), I 2 = 9.06% for the endoscopic vs combined approach; 1.61 (95% CI, 1.06 to 2.43, p = 0.025), I 2 = 0.00% for the external vs combined approach. After adjusting for publication bias, the adjusted RRs were 0.66 ( p = 0.014) for endoscopic vs external; 0.99 ( p = 0.955) for endoscopic vs combined; and 1.33 ( p = 0.224) for external vs combined. Conclusion An enlarging and maturing body of literature continues to indicate that endoscopic approaches result in significantly lower recurrence rates than open approaches for surgical resection of SIP.

BackgroundOlfactory nerve fibers are at risk of injury during transnasal endoscopic skull‐base approaches. Olfactory outcomes for various techniques have not been thoroughly investigated. This study aims to report long‐term olfactory outcomes when a cold knife upper septal limb incision technique is used compared to monopolar cautery.MethodsA prospective cohort study was performed at a tertiary referral center. Adult patients undergoing endoscopic approaches with septal incisions were randomized to cold knife or monopolar cautery groups. Patient demographics, clinical history, surgical data, and outcomes were collected. Preoperative, 3‐month, and 12‐month postoperative scores on the University of Pennsylvania Smell Inventory Test (UPSIT) and 22‐item Sino‐Nasal Outcome Test (SNOT‐22) were measured. Fisher's exact tests were performed for categorical variables and t tests were performed for continuous variables.ResultsTwenty‐two (22) patients (10 cold knife, 12 cautery) were enrolled between March 2016 and August 2017. The average age ± standard deviation was 50.2 ± 14.0 years (p = 0.59), 54% (p = 0.69) were female, and the primary pathology was pituitary adenoma (73%, p = 1.00). Preoperative, 3‐month, and 12‐month postoperative UPSIT scores were similar between the cold knife and cautery groups (32.8 vs 32.4, p = 0.80; 33.1 vs 33.0, p = 0.96; 33.6 vs 33.3, p = 0.84). On the “sense of smell/taste” question of the SNOT‐22, there was also no difference at all time points (p > 0.22).ConclusionThere was no significant change in patient UPSIT scores 1 year after transnasal skull‐base approaches, and no short‐term or long‐term differences between cold knife and cautery upper septal limb incision techniques. Our study supports an individualized approach based on surgeon preference.

Background There is little data regarding postoperative outcomes of patients with obstructive sleep apnea (OSA) undergoing skull base surgery. The purpose of this study is to determine an association between risk factors and proximity of cerebrospinal fluid (CSF) leak to surgery in patients with OSA undergoing endoscopic skull base surgery. Methods A retrospective review of neurosurgical inpatients, with and without OSA, at a tertiary care institution from 2002 to 2015 that experienced a postoperative CSF leak after undergoing endoscopic skull base surgery. Results Forty patients met inclusion criteria, 12 (30%) with OSA. OSA patients had significantly higher body mass index (BMI; median 39.4 vs. 31.7, p < 0.01) and were more likely to have diabetes (41.7 vs. 10.7%, p = 0.04) than non-OSA patients; otherwise there were no significant differences in clinical comorbidities. No patients restarted positive pressure ventilation (PPV) in the inpatient setting. The type of repair was not a significant predictor of the time from surgery to leak. Patients with OSA experienced postoperative CSF leak 49% sooner than non-OSA patients (Hazard Ratio 1.49, median 2 vs. 6 days, log-rank p = 0.20). Conclusion Patients with OSA trended toward leaking earlier than those without OSA, and no OSA patients repaired with a nasoseptal flap (NSF) had a leak after postoperative day 5. Due to a small sample size this trend did not reach significance. Future studies will help to determine the appropriate timing for restarting PPV in this high risk population. This is important given PPV's significant benefit to the patient's overall health and its ability to lower intracranial pressure.

BackgroundThe International Frontal Sinus Anatomy Classification (IFAC) is an international consensus document published in 2016 to standardize the nomenclature of cells in the region of the frontal recess and frontal sinus. The IFAC was designed to be surgically relevant and anatomically precise. The current study was undertaken to assess the prevalence of the frontal cell variants as defined by the IFAC, as well as to determine the interrater reliability of the IFAC.MethodsThree independent reviewers examined triplanar nondiseased maxillofacial computed tomography (CT) scans to assess the anatomy of the frontal recess according to the IFAC system. The prevalence of each cell type was assessed and interrater reliability was measured using an intraclass correlation coefficient (ICC).ResultsOne hundred CT scans (200 sides) were examined. Of the 200 sides, 96.5% contained an agger nasi cell (ICC, 0.82; 95% confidence interval [CI], 0.77‐0.86), 30.0% contained a supra agger cell (ICC, 0.89; 95% CI, 0.86‐0.92), 20.0% contained a supra agger frontal cell (ICC 0.80; 95% CI 0.74‐0.84), 72.0% contained a supra bulla cell (ICC, 0.81; 95% CI, 0.76‐0.85), 5.5% contained a supra bulla frontal cell (ICC, 0.71; 95% CI, 0.63‐0.77), 28.5% contained a supraorbital ethmoid cell (ICC, 0.78; 95% CI, 0.72‐0.83), and 30.0% contained a frontal septal cell (ICC, 0.80; 95% CI, 0.74‐0.84). The ICC was good to excellent for identification of all frontal cell types.ConclusionsThis study describes the normative distribution of frontal recess cells in a nondiseased population according to IFAC and demonstrates favorable interrater reliability of the classification system.

Background While Eustachian tube dysfunction (ETD) is a known comorbidity of chronic rhinosinusitis (CRS), the prevalence of ETD symptoms in the CRS population is poorly understood. We sought to determine the cross‐sectional prevalence of ETD in patients with CRS using the validated Eustachian Tube Dysfunction Questionnaire (ETDQ‐7) and to correlate ETDQ‐7 scores with 22‐item Sino‐Nasal Outcome Test (SNOT‐22) scores, endoscopy scores, and computed tomography (CT) scores. Methods A total of 101 patients with confirmed CRS completed the ETDQ‐7 and SNOT‐22 at their initial visit to our rhinology clinic. Lund‐Mackay CT and Lund‐Kennedy endoscopy scores were also obtained. Spearman's correlation coefficient (ρ) was calculated. Results Among the 101 patients, 49 patients (48.5%) had an ETDQ‐7 score of ≥14.5, signifying clinically significant ETD. The mean ± standard deviation (SD) ETDQ‐7 score of the entire cohort was 17.8 ± 10.1. There was a moderately strong correlation between ETDQ‐7 and the SNOT‐22 ear subdomain (ρ = 0.691, p < 0.001). The correlation coefficient between ETDQ‐7 and total SNOT‐22 scores was ρ = 0.491 ( p < 0.001), indicating moderate correlation. ETDQ‐7 scores were poorly correlated to objective measures of sinonasal disease, including Lund‐Mackay CT score (ρ = −0.055, p = 0.594) and Lund‐Kennedy endoscopy score (ρ = −0.099, p = 0.334). Conclusion Symptoms of ETD are highly prevalent among patients with CRS as documented by patient‐reported outcome measures. The correlation between ETDQ‐7 scores and SNOT‐22 ear subdomain scores is moderately strong, while the correlation between ETDQ‐7 scores and SNOT‐22 scores is moderate. ETD severity does not correlate with CT score or nasal endoscopy score.

BackgroundEndoscopic Draf 2B and Draf 3 frontal sinusotomies are frequently performed for chronic refractory frontal rhinosinusitis. The purpose of this study was to compare outcomes between Draf 2B and Draf 3 procedures.MethodsA retrospective cohort study was conducted comparing patients undergoing bilateral Draf 2B vs Draf 3 procedures from 2000 to 2016. Patients with neoplasia, dysplasia, mucocele, cystic fibrosis, or ciliary dyskinesia were excluded. Preoperative disease parameters included number of prior surgeries, presence of polyps, preoperative 22‐item Sino‐Nasal Outcome Test (SNOT‐22) score, frontal Lund‐Mackay score, anterior‐posterior diameter of the frontal ostium, and Global Osteitis Scoring Scale (GOSS). Postoperative outcomes included SNOT‐22 score, neo‐ostium patency, surgical revision rates, and complications.ResultsA total of 21 patients with bilateral Draf 2B and 17 patients with Draf 3 surgeries were compared. Mean follow‐up time was 15.6 months. No significant differences were seen between groups for any preoperative disease parameter. Both cohorts showed statistically significant (p = 0.0001 [Draf 2B]; p = 0.0001 [Draf 3]) and clinically meaningful (Δ = 24.1; Δ = 24.9) improvements in SNOT‐22 at last follow‐up vs preoperatively. The Draf 2B group had greater improvement in SNOT‐22 score than the Draf 3 group at 1 to 3 months (p = 0.003), but the magnitude of improvement equalized at 5 to 9 months (p = 0.66) and last follow‐up (p = 0.90). No significant differences were noted between groups regarding patency, revision rates, or complications.ConclusionBoth Draf 2B and Draf 3 procedures offer durable symptomatic improvement for patients with refractory frontal CRS. The Draf 2B is associated with earlier postoperative symptom improvement and overall shows comparable long‐term outcomes to the Draf 3 sinusotomy.