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Background Sinus computed tomography (CT) is performed for the diagnosis of paranasal sinus disease and to assess response to medical therapy. In addition, sinus CT is used for intraoperative imaging guidance. Multiple CTs increase cost and radiation exposure. Objective To determine potential cost savings and radiation dose reduction that result from the use of a single universal sinus CT protocol for diagnostic imaging and intraoperative navigation. Materials and Methods For sinus CT at the authors' institution, a single imaging protocol was begun and deemed acceptable by neuroradiologists and surgeons for diagnostic imaging and intraoperative guidance. The electronic medical record was queried over a 4-year period to determine the number of sinus CTs performed, dose-length products, referring providers' specialties, percentage of CTs used for intraoperative navigation, and the elapsed time between CT and surgery. Results A total of 6187 sinus CTs were performed by using a 64-detector scanner during the study period (2759 women and 3428 men; 53.6 ± 16.7 years [mean ± SD]), and 596 endoscopic sinus surgery cases used imaging guidance, for which all the CTs were deemed technically adequate. The mean dose-length product for the CTs was 338.4 ± 31.9 mGy-cm (mean ± SD). Of the 3702 sinus CTs ordered by nonotolaryngology providers, 167 surgeries with intraoperative navigation (4.5%) were performed. A higher percentage of CT referrals from sinus surgeons (23.9%) and other otolaryngology providers (11.4%) was used for imaging guidance (p < 0.0001). The time interval between sinus CT and surgery was greatest for nonotolaryngology providers (63.1 days, p < 0.01). Based on Medicare reimbursement, the total estimated saving was $147,628. Conclusions Adopting a single universal sinus CT protocol for diagnostic imaging and intraoperative navigation can be an effective means of decreasing cost and radiation exposure. However, successful implementation must take into account multiple practice-based considerations.

BackgroundThe objective of this study was to investigate gender‐specific differences in chronic rhinosinusitis (CRS) patients electing endoscopic sinus surgery (ESS).MethodsThis study was a retrospective review of CRS patients electing ESS (2011–2013) at a tertiary‐care center.ResultsESS was elected by 272 patients (mean age 54.6 years; 48.5% female). Mean Lund‐Mackay computed tomography (CT) score was 10.9; total 22‐item Sino‐Nasal Outcome Test (SNOT‐22) score was 41.8. Compared to men, women electing ESS had lower CT score (10.1 vs 11.7; p = 0.01) but higher total SNOT‐22 score (44.9 vs 39; p = 0.02). Women reported significantly worse postnasal drainage (p < 0.0001) and embarrassment (p = 0.0021). SNOT‐22 scores declined with advancing age (women, p = 0.003; men, p = 0.0005). Reduction in CT scores with age was seen only in males (p = 0.03). Stratifying by age, females aged 61 to 80 years had higher SNOT‐22 scores compared to male counterparts (p = 0.04), whereas CT scores were similar. More women underwent surgery for CRS without nasal polyps (CRSsNP) (54.9%) whereas more men underwent surgery for CRS with nasal polyps (CRSwNP) (57.4%), but this difference missed statistical significance (p = 0.052). Women with CRSwNP had higher SNOT‐22 scores than men (p = 0.02) for similar CT scores. Men electing ESS for CRSsNP had higher CT scores than women (p = 0.02). Women with CRSsNP aged 18 to 40 years reported higher SNOT‐22 scores than men (p = 0.003), even though CT scores were lower (p = 0.005).ConclusionEquivalent numbers of men and women underwent ESS for CRS. Overall, women electing ESS had higher total SNOT‐22 scores and lower Lund‐Mackay CT scores than men. Women reported more problems with postnasal drainage (CRS overall, CRSsNP, and CRSwNP), embarrassment (CRS overall and CRSwNP), and facial pain (CRSwNP). Gender differences in CRS are poorly understood and merit further study.

BackgroundThe objective of this work was to study patient and 22‐item Sino‐Nasal Outcome Test (SNOT‐22) characteristics in primary headache disorders (PHDs).MethodsRetrospective chart review of “sinus” headache/pressure/pain patients was conducted. Patients that had rhinosinusitis excluded (negative endoscopy/computed tomography [CT]), and neurologist‐confirmed PHD were studied. Patterns in symptom and SNOT‐22 items were analyzed by network visualization and cluster analysis.ResultsForty‐six patients met study criteria. Forty‐three (93.5%) reported “need to blow nose” and 40 (86.9%) reported postnasal drainage. Sneezing was reported by 37 (80.4%) patients, “blockage/congestion of nose” by 33 (71.8%), and “runny nose by 32 (69.6%) patients. The median SNOT‐22 score was 54 (interquartile range [IQR], 40 to 63). Past history included neurological diagnoses (60%), rhinologic disease (39%; chronic rhinosinusitis [CRS], rhinitis, recurrent acute sinusitis), asthma (28%), and allergen‐sensitivity (26%). Previous sinonasal surgery had been performed in 41%. Network layout and cluster analysis identified 2 patient clusters and 2 symptom clusters. Two‐thirds (31) of patients formed a tight cluster (cluster 1) linking to a symptom cluster of psychosocial items wrapped tightly with “facial pain/pressure.” The remaining one‐third of patients (cluster 2) linked to rhinologic symptoms loosely grouped away from “facial pressure/pain.” In contrast to patients in cluster 2, patients in cluster 1 were predominantly female (p < 0.04), had significantly higher (p < 0.0001) median SNOT‐22 scores (60 vs 34; IQR, 53 to 67 vs 17 to 42), were more likely to have migraine history (p = 0.058), and reported being “sad” (p < 0.0001) or “embarrassed” (p < 0.006).ConclusionProminent rhinologic symptoms can be present in PHD patients in the absence of rhinosinusitis. In particular, high symptom‐burden/SNOT‐22 scores and high psychosocial symptoms should raise suspicion of PHD when endoscopy and/or CT results do not correlate with symptoms.

Our objective was to perform a systematic review of the literature on contemporary indications and outcomes for frontal sinus trephination and present an illustrative case of an endoscopically assisted repair of a subcutaneous frontal sinus fistula by trephination technique. PubMed and Ovid databases were used as data sources. A systematic review of the English literature was completed to review reports of frontal trephination from 1980 to 2014. Articles meeting inclusion criteria for inflammatory and noninflammatory indications were reviewed. Articles were systematically reviewed and graded by evidence‐based medicine level. An illustrative case from our institution is then presented. The systematic review identified 2,621 published studies. Thirty‐eight studies were identified for inclusion. The indications, techniques, outcomes, safety, and complications were reviewed for noninflammatory and inflammatory conditions. There were 32 retrospective case series, reports, or cohort studies (level 4), four systematic reviews (level 3), one prospective analysis (level 3), and one meta‐analysis (level 2). Due to the heterogeneity of study cases and inclusion criteria, a meta‐analysis was not feasible. We also present a novel closure of an anterior skull base defect resulting in a subcutaneous fistula with use of a frontal trephination approach. The frontal sinus trephination should not be regarded as a procedure of the past, as it useful in the armamentarium of the modern sinus and skull base surgeon. This approach provides access for instrumentation for hard‐to‐reach frontal sinus disease either purely through a trephination approach or as a supplementation to the transnasal endoscopic approach. Evidence supporting frontal sinus trephination is of levels 2, 3, and 4.Level of EvidenceNALaryngoscope, 125:2046–2053, 2015

We report a case of sinonasal phosphaturic mesenchymal tumor (PMT) and conduct a systematic review of the literature to highlight a unique paraneoplastic syndrome associated with PMT. We used English language publications from Medline and Cochrane databases (1970–2013) as data sources. A systematic review of the literature was conducted. All reported cases of head and neck PMTs were included. The presence or absence of the associated paraneoplastic syndrome was noted. We found 33 cases of PMT in the head and neck reported in the literature, 17 of which occurred in the sinonasal area. Approximately 5% of all PMTs are located in the head and neck. Just greater than half are concentrated in the sinonasal area, and the remaining involve various bony and soft tissue structures of the head and neck. PMT is sometimes associated with a paraneoplastic syndrome of tumor-induced (oncogenic) osteomalacia (TIO) causing bone pain, muscle weakness, and pathologic fractures. We present the 18th reported case of sinonasal PMT. A smooth mucosa-covered midline intraseptal mass filling the posterior nasal cavity with destruction and erosion of the skull base was found in an adult male. The patient underwent successful endoscopic resection with wide negative margins and is without recurrence at 24-month follow-up. PMT is a benign, locally aggressive tumor with rare malignant transformation. Knowledge of the bony invasion and destruction caused by this tumor is essential in planning surgical resection with wide negative margins. Familiarity with the associated TIO is essential to investigate for and manage any associated bony morbidity.

SummaryBackgroundThe mechanisms and immune pathways associated with chronic rhinosinusitis (CRS) are not fully understood. Immunological changes during acute exacerbation of CRS may provide valuable clues to the pathogenesis and perpetuation of the disease.ObjectiveTo characterize local and systemic immune responses associated with acute worsening of sinonasal symptoms during exacerbation in CRS with nasal polyps (CRSwNP) compared to controls.MethodsThis was a non‐interventional prospective study of individuals with CRSwNP and normal controls. Subjects underwent a baseline visit with collection of nasal secretions, nasal washes, and serum specimens. Within 3 days of acute worsening of sinonasal symptoms, subjects underwent a study visit, followed by a post‐visit 2 weeks later. The sinonasal outcome test‐22 (SNOT‐22) scores and immunological parameters in the specimens were analysed using a novel, unsupervised learning method and by conventional univariate analysis.ResultsBoth CRSwNP patients and control subjects showed a significant increase in SNOT‐22 scores during acute exacerbation. Increased nasal levels of IL‐6, IL‐5, and eosinophil major basic protein were observed in CRSwNP patients. A network analysis of serum specimens revealed changes in a set of immunological parameters, which are distinctly associated with CRSwNP but not with controls. In particular, systemic increases in VEGF and GM‐CSF levels were notable and were validated by a conventional analysis.ConclusionsCRSwNP patients demonstrate distinct immunological changes locally and systemically during acute exacerbation. Growth factors VEGF and GM‐CSF may be involved in the immunopathogenesis of subjects with CRS and nasal polyps experiencing exacerbation.

Objectives/HypothesisTo study differential diagnosis and efficacy of management strategies in patients presenting to an otolaryngologist for sinus pressure, pain, or headache.Study DesignRetrospective analysis at an academic medical center.MethodsPatients were seen in the clinic (2010–2012) for sinus‐related headache, pressure, pain or fullness (study symptoms) by a rhinologist. A retrospective chart review of patients with study symptoms was conducted.ResultsOf 211 patients with study symptoms, 70.62% met American Academy of Otolaryngology–Head and Neck Surgery criteria for sinusitis or had rhinologic disease. Otolaryngic therapy alone (medical or surgical) relieved study symptoms in 51.66%; combined neurology intervention helped another 15.17%. Nearly half of the patients (48.82%) were diagnosed with primary headache disorders. Comorbid rhinologic‐neurologic disease was present in 27.96% and odontogenic disease in 7%. Initial otolaryngology referral was likely unnecessary for 36.49% of the study patients. Sinus computed tomography (CT) was available for 91% of 211 patients, and 80% of scans were positive. Endoscopic sinus surgery (ESS) was used in only 80/211 patients (37.69%) and was effective in 66/211 (31.28%). ESS was most successful in patients receiving concurrent neurological intervention. The Lund‐Mackay CT score did not predict outcomes from ESS. Interdisciplinary otolaryngology‐neurology efforts resulted in a positive outcome for 92.4% of patients.ConclusionsWe present the first series detailing management of patients with sinus‐headache pain in an otolaryngology practice. Such symptoms have multifactorial etiologies. Positive sinus CT results require cautious interpretation. ESS should be judiciously used. Interdisciplinary care is critical for success: approximately 50% of patients benefited from otolaryngic management, 50% needed neurological treatment, and 7% required dental disease management.Level of Evidence4 Laryngoscope, 125:303–310, 2015

ObjectiveIgG4‐related disease (IgG4RD) causing sinonasal and skull base pathology is uncommonly described. We present a series of suspected IgG4RD patients, with a pertinent review of the literature to highlight diagnostic challenges.Study DesignCase series.SettingAcademic tertiary care center.Subjects and MethodsCase series of patients with IgG4RD or suspected IgG4RD involving the sinonasal cavity and skull base.ResultsWe present 4 patients with atypical sinonasal and/or skull base disease who were noted to have IgG4‐positive plasma cell infiltration on immunohistochemistry of biopsy specimens. IgG4RD, a recently described entity affecting multiple organs, is characterized by lymphoplasmacytic infiltration and often elevated serum IgG4. IgG4RD can masquerade as malignancy or infection but responds to glucocorticosteroid and immunosuppressant therapy. IgG4RD has been infrequently reported presenting as sinonasal or skull base lesions, and definitive diagnostic criteria for these regions are not established. In our series, IgG4RD was suspected in all 4 patients, but only 1 met all current criteria for definitive diagnosis. All 4 patients, however, responded to corticosteroid therapy, and 1 was placed on long‐term azathioprine.ConclusionIgG4RD is rarely described in the sinonasal cavity and skull base, and specific diagnostic criteria for such disease have not been defined. We present a series of patients with IgG4‐positive plasma cell inflammatory pathology who were suspected to have IgG4RD. Our series highlights diagnostic challenges associated with these patients. Tumefactive and destructive sinonasal‐skull base lesions with a plasma cell‐rich infiltrate should incite suspicion of IgG4RD, and immunohistochemistry for IgG4‐positive plasma cells should be performed.

BackgroundWe report the first report of an expansile crista galli (CG) mucocele treated surgically by an endoscopic endonasal approach. Only 1 other case of a CG mucocele has been previously reported in the literature. This was treated by a craniotomy approach.Case ReportWe describe the technique employed in endoscopic marsupialization. We also discuss relevant CG anatomy, pneumatization patterns, surgical approaches, and its potential to cause disease, including CG sinusitis and mucocele formation.ConclusionWe present this case to highlight that the growing experience with endoscopic techniques offer us less morbid and more functional alternatives to a variety of lesions that were once tackled by neurosurgical or external approaches. In the contemporary era, the indications for open approaches and craniotomy for frontal sinus and CG lesions is likely limited. We recommend these patients undergo careful evaluation by a surgeon experienced in advanced endoscopic techniques before being advised to undergo open or craniotomy techniques.