Lal, Devyani

ABSTRACT Background Optimizing access to cost‐effective care in capacity‐constrained health systems is a contemporary imperative. We evaluated whether machine learning (ML) models using patient‐reported data could optimize access for patients requiring surgical care in rhinology clinics, without need for CT imaging. The outcome was defined as any rhinologic surgery within 90 days of initial evaluation. Methods A de‐identified electronic dataset from patients seen at five distinct sites within an integrated healthcare system between 2018 and 2025 was used to train models. Demographic data and 22‐item Sinonasal Outcome Test (SNOT‐22) responses were studied. Models were trained using stratified 5‐fold cross‐validation with an 80% development cohort and validated in a 20% held‐out validation cohort. Hyperparameters were optimized with Optuna. The primary outcome was performance of any rhinologic surgical intervention within 90 days of initial SNOT‐22. Results Data from 35,170 patients were evaluated. Item‐level responses outperformed use of total SNOT‐22 score in the models. Among models, XGBoost demonstrated best discrimination with AUC of 0.70 (95% CI, 0.69–0.71), outperforming logistic regression (0.66), random forest (0.63), and TabNet (0.66) (all p < 0.001). At optimal threshold, XGBoost achieved 66% sensitivity, 64% specificity, 28% PPV, and 90% NPV. Top predictors for surgery were age, nasal blockage, facial pain or pressure, and decreased sense of smell or taste. Validation on the held‐out cohort remained stable (AUC 0.70), with strong discrimination across sites despite surgical rates ranging from 11.5% to 27.4%. Conclusions Demographics and item‐level SNOT‐22 responses were successful in developing an ML model that demonstrated moderate discrimination and high NPV (90%) for performance of surgery within next 90 days. ML models balanced with human oversight may accelerate triage and optimize surgical yield for rhinology clinics.

ABSTRACT Objective Odontogenic sinusitis (ODS) ranges from isolated maxillary disease to pansinusitis. We compared patient characteristics, microbial and histopathological features, and symptom outcomes following endoscopic sinus surgery (ESS) between low and high radiographic burden ODS patients. Methods ODS patients undergoing ESS between 01/2013 and 08/2024 were reviewed. Preoperative CT scans were used to classify patients into high radiographic burden [with ostiomeatal complex (OMC) opacification] and low radiographic burden ODS [clear OMC]. Demographic, microbiological, and histopathological data were analyzed. Symptom improvement was assessed using pre‐ and post‐operative SNOT‐22 scores. Results Eighty‐seven patients were identified (high CT burden: 70; low CT burden: 17). High CT burden ODS was associated with older age ( p = 0.014), higher overall degree of inflammation ( p = 0.002), hyperplastic/papillary epithelial changes ( p = 0.034), and neutrophil infiltration ( p = 0.003). Culture of classic ODS bacteria ( Fusobacterium spp., Prevotella spp., mixed anaerobes, Streptococcus anginosus group) did not correlate with CT disease burden ( p = 0.110). No independent predictors of radiographic high‐burden disease were identified. Post‐ESS, significant reduction in total and rhinologic SNOT‐22 scores was only observed in the radiographic high‐burden ODS group ( n = 39; median reductions: 23 and 12 respectively; p < 0.001). Conclusion High radiographic burden was associated with older patients and with tissue inflammation level. Classic ODS bacterial profile did not associate with increased CT burden. While these findings remain exploratory, the observed differences in inflammatory and symptomatic profiles between groups suggest that radiographic burden warrants further study as a potential factor in ODS clinical decision‐making. Level of Evidence 3.

ABSTRACT Objective Surgical repair and 3D‐printed customized septal prosthesis (3D‐PCSP) are options for septal perforation treatment. We performed a study to compare the clinical outcomes of surgery and 3D‐PCSP using the NOSE‐Perf Scale (NPfS). Methods A chart review was performed on patients undergoing surgical repair or 3D‐PCSP placement between January 2018 and July 2024. The change in NPfS was used as primary endpoint. Demographics, ASA score, perforation size, etiology, and follow‐up duration were reported. Results Thirty‐five patients, 23 for surgical repairs and 12 for 3D‐PCSP, were included in this review [median (IQR)]. In the surgical repair group, perforation length and height measured 12 (10–18) mm and 10 (8–15) mm, respectively. Baseline NPfS was 24 (16–32), and this decreased to 8 (6–13) following surgical repair ( p < 0.001). Follow‐up time was 12 (5–21) months. In the 3D‐PCSP group, septal perforation length and height measured 25 (15–30) mm and 17 (15–20) mm, respectively. The baseline NPfS was 17 (3–24.5), and this decreased to 9.5 (7–13) following 3D‐PCSP placement ( p = 0.001). The follow‐up was 18.4 (16–23) months. NPfS reduction was greater for surgical repair ( p = 0.018). Conclusions Surgery and 3D‐PCSP offer meaningful symptom relief for NSP patients. Treatment decisions should be individualized through shared decision‐making that considers patient comorbidities, preferences, surgeon experience, and risk tolerance. In this cohort, surgical repair was associated with greater NPfS reduction compared with 3D‐PCSP placement. Level of Evidence 3.

ABSTRACT Objectives We evaluated the impact of teprotumumab therapy ( TT ) introduction on orbital decompression ( OD ) utilization for thyroid eye disease ( TED ) and compared rates of significant exophthalmos reduction ( SER ) and diplopia between TT and OD . Methods Newly diagnosed TED patients treated pre (2015–2020) and post teprotumumab (2020–2025) FDA approval were identified from the EHR . Utilization trends, diplopia rates, and immediate (≤ 6 weeks post‐intervention) and long‐term follow‐up SER (≥ 2 mm reduction) were studied. Results Of 406 TED patients, 53 (36.8%) underwent OD in the pre‐ TT cohort ( n = 144). Post‐teprotumumab approval ( n = 262), primary OD was performed in 29 (11.1%), of which 3 (10.3%) were subsequently placed on TT ; primary TT was used in 68/262 (25.9%) with subsequent OD performed in 9 (13.2%). The remaining patients used other treatments (corticosteroids, orbital radiation, rituximab, tocilizumab, etc.). In the overall cohort, immediate SER was achieved in 94.4% of OD versus 83.8% of TT patients ( p = 0.028), with greater median reduction in the OD group (5 vs. 4 mm; p = 0.001). At long‐term follow‐up (median 13 vs. 12 months), SER was sustained in 85.4% of OD and 62.9% of TT patients ( p = 0.042). Pre‐therapy diplopia was more prevalent in TT vs. OD patients (79.4% vs. 59.7%; p = 0.019). New‐onset posttreatment diplopia was higher in the OD group (20.7% vs. 5.9%; p = 0.008). Conclusions Rates of OD surgery declined following FDA approval of teprotumumab. OD achieved sustained and greater exophthalmos reduction but carried a higher risk of diplopia. Contemporaneous OD indications may have evolved to use in TT‐recalcitrant TED or those in need of urgent decompression. Level of Evidence 4.

Key Points Contemporary aspirin exacerbated respiratory disorder (AERD) therapy commonly includes aspirin desensitization (55%) and biologics (48%). Aspirin desensitization therapy has higher discontinuation rates than biologics. Patients receiving biologics are younger, and ∼25% of the patients switch to other agents.

ABSTRACT Objectives To review septal perforation management and outcomes in patients with hereditary hemorrhagic telangiectasia (HHT). Methods Collection and presentation of patient demographic, perforation size, and prior perforation and HHT treatment data over a 20‐year period. Symptom and quality of life treatment outcomes were determined using the Nasal Obstruction Symptom Evaluation (NOSE)‐Perf scale and the 5‐Factor Glasgow Inventory (GBI‐5F), respectively, in patients treated since 2017. Results Nine patients met study criteria. Mean (range) age was 64.4 (52–80) years and seven were biological males. Mean (range) perforation length and height were 1.9 (1.2–2.6) and 1.4 (1.0–1.8) cm. Four patients were treated with a customized septal button, one with posterior septal resection, and four with endonasal bilateral mucosal flap repair supported with an interposition graft. The button prostheses were well tolerated and the surgical closures successful at 8–60 months postoperatively. Subjective responses in the first three patients, and NOSE‐Perf with GBI‐5F scores in the latter six patients, demonstrated symptom and quality of life improvement for all patients. Perforation repair patients demonstrated substantial improvement in mean GBI‐5F subdomain scores for quality of life, self‐confidence, and social involvement and all have undergone sodium tetradecyl sclerotherapy injection postoperatively without re‐perforation. Conclusion Symptom and quality of life improvement can be achieved in HHT patients with a perforation using customized septal buttons, posterior septal resection, or bilateral flap surgical repair. Surgical closure combined with injection sclerotherapy is feasible with a low risk of re‐perforation and represents an effective treatment strategy in selected patients. Level of Evidence 4.

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.