Background:Juvenile nasopharyngeal angiofibroma (JNA) is a rare locally aggressive vascular sinonasal tumor that primarily affects adolescent males. Despite advances in endoscopic surgery and preoperative embolization, JNA can be associated with major operative bleeding risk and clinically meaningful recurrence, while non-surgical treatment options remain limited. Methods:To define the cellular programs underlying JNA vascularity, we performed single-cell RNA sequencing of JNA tumors (n=2), tumor-adjacent mucosa, and control sinonasal tissue. We analyzed cell composition, differential gene expression, pathway enrichment, and cell-cell communication, followed by Drug2cell-based mapping of transcriptional states to candidate therapeutic targets. Results:JNA contained an expanded fibrovascular compartment composed of endothelial cells, fibroblasts, pericytes, vascular smooth muscle cells, and neural crest-like cells. Neural crest-like cells were enriched in JNA but showed relatively limited transcriptional differences from tumor-adjacent tissue. By contrast, endothelial cells demonstrated the strongest disease-associated remodeling, with enrichment of angiogenesis, extracellular matrix organization, hypoxia response, and cell migration pathways. Endothelial cells also showed downregulation of adaptive immune signaling pathways, suggesting reduced immune engagement within the tumor microenvironment. Intercellular communication analyses revealed dense endothelial-stromal signaling across the JNA fibrovascular network. Drug2cell analysis nominated VEGF/VEGFR signaling as a candidate therapeutic vulnerability, with VEGFR-targeting agents predicted to act primarily on vascular and lymphatic endothelial populations. Conclusions:JNA is organized around an angiogenesis-dominant fibrovascular program driven by endothelial-centered signaling. These data support further investigation of VEGF/VEGFR-directed therapy as a potential adjunctive strategy for patients with recurrent, unresectable, or surgically high-risk JNA.

INTRODUCTION:Social determinants of health (SDoH) impact surgical outcomes, risk-adjusted prognoses, and overall health. The Social Vulnerability Index (SVI) measures SDoH based on 16 social factors. This study evaluates the impact of social vulnerability on the quality of life of those living with chronic rhinosinusitis (CRS). METHODS:A retrospective cohort review of 657 patients at a single institution. CRS patients with cystic fibrosis, nasal obstruction, and nasal cancer were excluded. Baseline covariates, including SNOT-22 scores, sex, and history of surgery, were collected. SVI was calculated using the National Social Vulnerability Index 2020 Database by Census Tract. Statistical analyses were conducted. RESULTS:A lower SVI score was associated with lower SNOT-22 scores, independent of sex, presence of polyps, or history of surgery (p < 0.001). Patients in the "Low to Medium" SVI category were significantly less likely to undergo surgery compared to those in other SVI categories (p = 0.04). Compared to patients with CRSwNP, those with CRSsNP had significantly worse SNOT-22 scores (p = 0.038) but no significant difference in SVI scores. Surgery was performed in 69% of patients with CRSsNP and 84% of those with CRSwNP. CONCLUSION:Social vulnerability impacts the likelihood of surgery and quality of life in patients with CRS. Higher vulnerability is associated with worse sinonasal symptoms, regardless of confounders. CRS patients with lower social vulnerability are less likely to have surgery. SNOT-22 scores did not influence the likelihood of surgery. LEVEL OF EVIDENCE: 3:

KEY POINTS:Bevacizumab reduced epistaxis-related ablation frequency by 55.6% in HHT patients. Over half of HHT patients (57.7%) required no ablation intervention after bevacizumab initiation. Maintenance bevacizumab dosing remains highly variable, underscoring the need for standardization.

OBJECTIVES:This study reviews current postoperative care recommendations following endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS), with the goal of optimizing recovery, minimizing complications, and reducing the risk of disease recurrence. METHODS:A comprehensive literature review was conducted to identify studies on postoperative care following ESS for CRS. Findings were synthesized to develop evidence-based recommendations for optimal postoperative management. RESULTS:Postoperative care following ESS for CRS requires a multifaceted approach. Pain management should prioritize acetaminophen and nonsteroidal anti-inflammatory drugs, with opioids reserved for severe pain. Nasal irrigation, topical corticosteroids, and debridement are recommended for all patients. Nasal packing and drug-eluting devices may offer additional benefits, but are not universally required. The use of antibiotics and oral corticosteroids should be selective and guided by individual patient factors and risk profiles. DISCUSSION:While general recommendations are made, patient-specific factors such as comorbidities, financial constraints, and adherence to care must be considered. Further evaluation of these factors is essential to establish a more comprehensive and individualized standard of care for postoperative management. CONCLUSIONS:Effective postoperative care following ESS for CRS should be individualized, multifaceted, and focused on improving recovery, minimizing complications, and ensuring the best possible patient outcomes.

Allergic fungal rhinosinusitis (AFRS) is a unique endotype of chronic rhinosinusitis with nasal polyps (CRSwNP). Despite high recurrence rates and often more severe presenting signs compared with other subtypes of CRSwNP, research dedicated to AFRS has been lacking. Diagnostic criteria are outdated, the mechanistic relationship of AFRS to other associated diseases is unclear, and the pathophysiology of disease and risk factors for recurrence have not been well studied. In December 2023, a multidisciplinary group of rhinologists, otolaryngologists, pulmonologists, allergists, immunologists, scientists, and infectious disease experts met at the National Institute of Health to discuss unmet needs for future AFRS research and care, including patient management, diagnostic criteria, severity, pathophysiology, and related conditions. A summary of these clinical and associated research discussions is included below.

Abstract Objective Individuals with primary ciliary dyskinesia (PCD) frequently report olfactory dysfunction, yet this deficit is poorly documented. The purpose of this study was to characterize the presence and degree of olfactory dysfunction in PCD compared to controls and determine whether certain PCD genes are associated with worse olfaction. Study Design A prospective cohort study. Setting Tertiary referral center. Methods We administered the University of Pennsylvania Smell Identification Test (UPSIT) to individuals with PCD. Participants were divided into 3 age groups (15‐29 years, 30‐44 years, and 45+ years) and compared to age‐ and sex‐matched normal controls (n = 2170). Results Twenty‐nine individuals with PCD (8 males and 21 females) met the criteria (median age: 38 years; interquartile range: 22‐47). Only 27.6% of patients with PCD had UPSIT scores within the normosmia range. The UPSIT median scores of each PCD age group were significantly lower than the median scores of the controls (P < .0001 for each age group). UPSIT scores generally worsened with age: mean 33 (mild hyposmia) for 15 to 29 years, 26.8 (moderate hyposmia) for 30 to 44 years, and 20.9 (severe hyposmia) for 45+ years. The most common genes coded were absent inner dynein arm/microtubule disorientation (IDA/MTD) defect (11/24, 45.8%), followed by absent outer dynein arm defect (8/24, 33.3%). The CCDC39 gene (IDA/MTD) was associated with worse olfactory dysfunction. Conclusion Individuals with PCD have a substantially higher prevalence and degree of olfactory dysfunction compared to age‐matched controls. Our study is the first to report greater olfactory dysfunction with age in PCD patients, highlighting an important area for research.

Objectives: This study aimed to evaluate MRI-based changes in olfactory bulb (OB) volume and area to predict the likelihood of OB invasion in olfactory neuroblastoma (ONB). Design: Retrospective review of MRI data. Setting: Conducted at Jikei University, Japan, and the University of North Carolina, USA. Participants: The study included 46 ONB-diagnosed patients undergoing MRI and surgical treatment. Main Outcome Measures: Preoperative volume and cross-sectional area of the OB were measured, and the surgical pathology of the OB was reviewed. Results: Significant differences in OB metrics were observed between patients with and without olfactory bulb/tract invasions. ROC analysis demonstrated high discriminative ability: OB volume (AUC=0.971, cutoff 60 mm³) and maximum cross-sectional area (AUC=0.941, cutoff 9.5 mm²) both showed high sensitivity and specificity for predicting OB invasion. The left-right OB difference, with a lesion/non-lesion ratio exceeding 175%, was a strong predictor. Conclusions: Quantitative MRI metrics of the OB are effective in predicting invasion in ONB. These findings may enhance diagnostic accuracy and influence treatment strategies. Further research is warranted to validate these findings in larger cohorts.

The purpose of the review is to summarize the current literature and evaluate how different environmental exposures may contribute to the development and course of chronic rhinosinusitis (CRS). The review aims to explore the relationship between host factors and environmental exposures in the pathogenesis of CRS. Recent studies have helped establish the role of air pollutants, tobacco smoke, occupational exposures, and microplastics in the pathogenesis of CRS. These exposures have been shown to cause epithelial dysfunction and promote inflammation through different mechanisms and to different degrees. The pathogenesis of CRS is complex and multifactorial, with environmental exposures playing a key role in its onset and exacerbation. Research indicates that pollutants can damage the sinonasal epithelial barrier and disrupt the microbiome, leading to increased inflammation. A deeper understanding of the mechanisms behind this inflammatory process and its link to environmental exposures could enhance strategies for preventing and treating CRS.

BackgroundThe representation of women in otolaryngology has increased significantly over recent decades, yet discrepancies remain in certain subspecialties, including rhinology. Despite overall improvements in gender equity within otolaryngology, the specific demographic trends and scholarly productivity of fellowship-trained rhinologists have not been thoroughly examined.ObjectiveWe aimed to address this gap by examining demographic trends and academic productivity among rhinology fellowship graduates.MethodsThis cross-sectional study examined publicly available data to analyze fellowship-trained rhinologists in the United States, focusing on gender, career stage, practice setting, h-index, and academic rank. Statistical analyses included Fischer's exact test, Wilcoxon rank sum test, ANOVA, and η2.ResultsWe included 477 fellowship-trained rhinologists who trained at 31 fellowships. No gender differences in career stage or practice type were found. Despite an absolute increase in women per year (0 to 9, η2 = 0.65), the percentage of women in rhinology fellowships has plateaued since 2002 (η2 = 0.001), averaging 21.1% (SD = 10.8%). Most fellowship-trained rhinologists were mid-career, with a median of 7 practice years; 55% worked in academics, mainly as assistant professors. Overall, women rhinologists had a slightly lower h-index than men (7 vs 9; P = .01), but when stratified by academic rank, there was no difference in h-index between men and women.ConclusionThe percentage of women fellowship-trained rhinologists has not increased since 2002 (η2 = 0.001), remaining at a mean of 21.1%. Contrasting with other subspecialties, women and men rhinologists have similar h-indices by academic rank. However, there are still fewer women in rhinology overall than men.

Objectives:This study evaluates the anatomical feasibility of an endoscopic transnasal approach for deep lateral orbital decompression using cadaver models. Design:Cadaver study. Participants:Four fresh frozen cadaver heads (eight sides) were used. Main Outcome Measures:Measurements of the sphenoid trigone before and after bone removal were assessed using CT scans. Key outcome measures included the width, height, depth, and volume of the trigone. Results:The transnasal approach achieved a 53.9% reduction in trigone volume, with significant decreases in height (65.0%), width (84.3%), and depth (76.8%). Preoperative measurements revealed an average orbital surface width of 20.0 mm, later reduced to 16.7 mm postoperatively. The average trigone depth was reduced from 16.1 to 12.0 mm, and height decreased from 21.3 to 13.4 mm in the postoperative assessment. The procedure showed a mild limitation in reduction along the cephalocaudal axis, with residual regions measuring 4.5 and 3.0 mm in the superior and inferior directions, respectively. Conclusion:The endoscopic transnasal approach effectively reduces the size of the sphenoid trigone, providing a promising alternative for orbital decompression with potential clinical applications. Future research should explore long-term outcomes and integration into surgical practice.

BACKGROUND:The measurement of olfaction in research has drawn significant attention due to its critical role in diagnosing and monitoring olfactory dysfunction (OD). Olfactory impairments are associated with various disorders, making accurate and reliable testing essential. Current assessment methods can be categorized into subjective and objective measures. Subjective tools provide information to evaluate an individual's perception and awareness of smells. Conversely, psychophysical (objective) measures provide quantifiable data that can detect olfactory impairments with precision but prove to be time-consuming and costly. The reliability of subjective assessments compared with objective methods remains a topic of ongoing investigation. There is a growing need for a comprehensive and efficient approach to measuring olfaction that balances accuracy, cost, and practicality. METHODS:This scholarly review examines and compares the outcomes of studies that have evaluated different olfactory assessment tools. Each study was chosen for its popularity among current otolaryngology providers. The effectiveness of these tests was analyzed based on sensitivity in detecting OD, ease of administration, and overall cost-efficiency. RESULTS:Findings highlight the strengths and limitations of both subjective and objective methods. Subjective assessments, while convenient and cost-effective, exhibit variability in reliability due to individual differences in olfactory perception and cognitive biases. Objective tests provide precise and standardized results, but their practical application is limited due to cost, expertise, and duration of testing. CONCLUSIONS:Current olfactory assessments present a trade-off between cost, reliability, and practicality. Objective methods are currently the gold standard, but their limitations necessitate the development of more accessible testing. Future research should focus on refining hybrid models that integrate subjective self-reports with validated objective measures to achieve a comprehensive and cost-effective approach to olfactory assessment.

International Forum of Allergy & RhinologyEarly View CLINICAL LETTER Ensuring the appropriate use of biologics: A call for specialty evaluation Aurelia Monk BA, Corresponding Author Aurelia Monk BA [email protected] Department of Otolaryngology—Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, USA Correspondence Aurelia Monk, Department of Otolaryngology—Head and Neck surgery, University of North Carolina, 170 Manning Drive, Campus Box #7070, Chapel Hill, NC 27599, USA. Email: [email protected]Search for more papers by this authorBrian D. Thorp MD, Brian D. Thorp MD Department of Otolaryngology—Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, USASearch for more papers by this authorBrent A. Senior MD, Brent A. Senior MD orcid.org/0000-0002-1503-3150 Department of Otolaryngology—Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, USASearch for more papers by this authorAdam J. Kimple MD, PhD, Adam J. Kimple MD, PhD Department of Otolaryngology—Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, USASearch for more papers by this authorCristine Klatt-Cromwell MD, Cristine Klatt-Cromwell MD Department of Otolaryngology—Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, USASearch for more papers by this authorCharles S. Ebert Jr. MD, Charles S. Ebert Jr. MD Department of Otolaryngology—Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, USASearch for more papers by this author Aurelia Monk BA, Corresponding Author Aurelia Monk BA [email protected] Department of Otolaryngology—Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, USA Correspondence Aurelia Monk, Department of Otolaryngology—Head and Neck surgery, University of North Carolina, 170 Manning Drive, Campus Box #7070, Chapel Hill, NC 27599, USA. Email: [email protected]Search for more papers by this authorBrian D. Thorp MD, Brian D. Thorp MD Department of Otolaryngology—Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, USASearch for more papers by this authorBrent A. Senior MD, Brent A. Senior MD orcid.org/0000-0002-1503-3150 Department of Otolaryngology—Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, USASearch for more papers by this authorAdam J. Kimple MD, PhD, Adam J. Kimple MD, PhD Department of Otolaryngology—Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, USASearch for more papers by this authorCristine Klatt-Cromwell MD, Cristine Klatt-Cromwell MD Department of Otolaryngology—Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, USASearch for more papers by this authorCharles S. Ebert Jr. MD, Charles S. Ebert Jr. MD Department of Otolaryngology—Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, USASearch for more papers by this author First published: 11 February 2024 https://doi.org/10.1002/alr.23333 Cristine Klatt-Cromwell and Charles S. Ebert Jr. are co-senior contributing authors. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. CONFLICT OF INTEREST STATEMENT The authors declare they have no financial disclosures or conflicts of interest. REFERENCES 1Bachert C, Han JK, Desrosiers M, et al. Efficacy and safety of dupilumab in patients with severe chronic rhinosinusitis with nasal polyps (LIBERTY NP SINUS-24 and LIBERTY NP SINUS-52): results from two multicentre, randomised, double-blind, placebo-controlled, parallel-group phase 3 trials. Lancet. 2019; 394(10209): 1638-1650. doi:10.1016/S0140-6736(19)31881-1 10.1016/S0140-6736(19)31881-1 CASPubMedWeb of Science®Google Scholar 2Hellings PW, Verhoeven E, Fokkens WJ. State-of-the-art overview on biological treatment for CRSwNP. Rhinology. 2021; 59(2): 151-163. doi:10.4193/Rhin20.570 10.4193/Rhin20.570 CASPubMedWeb of Science®Google Scholar 3Mullol J, Laidlaw TM, Bachert C, et al. Efficacy and safety of dupilumab in patients with uncontrolled severe chronic rhinosinusitis with nasal polyps and a clinical diagnosis of NSAID-ERD: results from two randomized placebo-controlled phase 3 trials. Allergy. 2022; 77(4): 1231-1244. doi:10.1111/all.15067 10.1111/all.15067 CASPubMedWeb of Science®Google Scholar 4Fokkens WJ, Viskens AS, Backer V, et al. EPOS/EUFOREA update on indication and evaluation of biologics in chronic rhinosinusitis with nasal polyps 2023. Rhinology. 2023; 61(3):194-202. doi:10.4193/Rhin22.489 10.4193/Rhin22.489 Web of Science®Google Scholar 5Han JK, Bosso JV, Cho SH, et al. Multidisciplinary consensus on a stepwise treatment algorithm for management of chronic rhinosinusitis with nasal polyps. Int Forum Allergy Rhinol. 2021; 11(10): 1407-1416. doi:10.1002/alr.22851 10.1002/alr.22851 PubMedWeb of Science®Google Scholar Early ViewOnline Version of Record before inclusion in an issue ReferencesRelatedInformation

The anteromedial temporal region and the lateral wall of the sphenoid can be the site of an array of pathology including trigeminal schwannoma, encephalocele, cholesterol granuloma of the petrous apex, malignancy, infection, and sellar pathology extending to the lateral cavernous sinus. Approaches to this region are technically challenging and the existing approach requires sacrifice of all of the turbinates including the nasolacrimal duct, which can cause postoperative complications. We describe a novel anatomical landmark between the periorbita and the periosteum of the pterygopalatine fossa (which is located at the inferolateral periorbital periosteal line [ILPPL]). The posterior one-third of the incision line lies between the foramen rotundum and the superior orbital fissure, which is proximal to the maxillary strut. A 1.5-cm incision can divide the orbital and pterygoid contents and lead us to the posterior inferolateral orbital region, anteromedial temporal region, lateral wall of the sphenoid sinus, and lateral wall of the cavernous sinus. A combined multiangled approach to the ILPPL will enable us to preserve all of the turbinates and the septum, and the nasolacrimal duct, allowing for the preservation of the physiological function and pedicled flaps, such as the middle turbinate, inferior turbinate, and septal membrane flap. The ILPPL is a simple, effective, and novel landmark for the minimally invasive approach to the anteromedial temporal fossa.

KEY POINTS:Automated plagiarism-checking software can be a valuable tool for detecting plagiarism in manuscripts. Twenty-five of 60 articles (42%) had at least one incidence of plagiarism, predominately text recycling. A "similarity score" ranging from 22% to 35% could be a potential cut-off value when screening submitted manuscripts.