INTRODUCTION:The fibula-free flap has traditionally been utilized to perform dental rehabilitation following maxillectomy. The purpose of this study is to present our experience with dental implantation of the scapula-tip-free flap in midface reconstruction. METHODS:Fifteen adult patients underwent midface reconstruction with dental implantation using the scapula tip between January 2013 and December 2023. Implant success was defined as maintenance of the implant after 6 months of healing with associated functional prosthetic rehabilitation. RESULTS:A total of 35 implants were placed into 15 scapula-free flaps. There were four implant failures (11.4%) that occurred in three patients (20%) during the study period resulting in an overall implant success rate of 88.6% with a median follow-up period of 2.8 years. All patients were restored with a removable implant overdenture. CONCLUSION:Dental implantation can be achieved in the scapula tip following maxillectomy with a high degree of success.

BACKGROUND:Chronic rhinosinusitis (CRS) is a prevalent, heterogeneous inflammatory disease associated with significant morbidity. Systemic corticosteroids (SCS) are commonly prescribed for their anti-inflammatory effects, but cumulative exposure carries risks, including metabolic, cardiovascular, and skeletal complications. Despite widespread use, evidence-based guidance on optimal indications, timing, and duration of SCS in CRS remains inconsistent. METHODOLOGY/PRINCIPAL:An evidence-based review was performed using MEDLINE, EMBASE, and Cochrane databases (2013-2023). Studies were screened and categorized into two primary groups: CRS with (CRSwNP) or without (CRSsNP) nasal polyps. Within CRSwNP, evidence was subcategorized by indication, including (1) polyp size reduction, (2) olfactory dysfunction, (3) comorbid disease, and (4) perioperative use, encompassing pre- and postoperative SCS administration. The CRSsNP category included studies evaluating SCS in non-polypoid disease, with or without comorbidities. Recommendations were graded according to evidence quality and the balance of benefit versus harm. RESULTS:Short courses of SCS provide consistent, short-term improvements in nasal polyp size, nasal congestion, and olfactory function in CRSwNP, but benefits wane within weeks unless followed by intranasal corticosteroids. Preoperative SCS improves intraoperative visualization, though comparable nonsteroidal techniques exist. Routine postoperative SCS are not supported, showing no meaningful advantage over topical therapy. No additional benefit was seen in comorbid subgroups. Evidence in CRSsNP is limited, with possible benefit only in early disease or select medically managed cases. Repeated use contributes to cumulative toxicity. CONCLUSIONS:SCS have a narrow, time-limited role in CRS. Stewardship should emphasize optimized topical therapy, appropriate sinus surgery, and biologics to minimize systemic steroid exposure.

OBJECTIVES:The aim was to evaluate the predictive potential of Sinonasal Radiological (SR) and the Lund-Mackay (LM) score of sinus computed tomography (CT) scans on postoperative relapses of chronic rhinosinusitis (CRS). MATERIALS AND METHODS:CRS patients (n = 483, 12-80 years) underwent routine sinus CT scans. The SR score was defined by obstructed frontal recess (0 = no, 1 = yes) and visualization of middle and inferior turbinate (0 = anatomy can be easily visualized, 1 = anatomy cannot be easily visualized) on each side (a total of 0-6 points). Associations were analyzed by nonparametric, survival and Cox's proportional hazard models. RESULTS:Revision endoscopic sinus surgery (ESS) was performed in 133 (28.0%) patients on average (min-max) of 3.2 (0-12) years after performing the sinus CT scans. Of the 408 patients who underwent the baseline ESS, high preoperative SR or LM scores significantly predicted revision ESS (p < 0.001) and peroral corticosteroid courses purchased during the follow-up (p = 0.009 and p < 0.001, respectively for SR- and LM-scores). In multivariable analysis, both SR score and asthma and/or NSAID exacerbated respiratory disease (N-ERD) were significantly associated with revision ESS risk (p = 0.035, p = 0.007, respectively). CONCLUSION:LM and SR and a history of asthma or N-ERD predict CRS relapses, which may help in decision-making.

INTRODUCTION:Previous studies have demonstrated a positive relationship between surgeon volume and patient outcomes. While this relationship has been established in oncologic, bariatric, and orthopedic surgeries, little is known in the realm of endoscopic sinus surgery (ESS). The objective was to assess the association between a surgeon's ESS annual volume and rates of revision surgery within 5 years as well as 30-day complications for patients with chronic rhinosinusitis (CRS). METHODS:We identified CRS patients in Ontario, Canada, who underwent primary ESS, using surgeon-level administrative data between 2014 and 2018 (N = 13,562). Surgeon volume was calculated based on the number of procedures performed in the previous year by the surgeon and was divided into quartiles. We identified those who underwent revision ESS within the subsequent 5-year period. Complications were defined as unplanned hospital admission or emergency department visit within the first 30 days following the operation. A multivariate regression model was used to estimate the effect of surgeon volume on revision rate. RESULTS:An unadjusted model demonstrated that high surgeon volume quartile (> 63/year) was associated with lower rates of revision surgery and 30-day hospitalization (p < 0.05 for both) along with a higher rate of complete ESS (p < 0.001). After controlling for patient/surgeon covariates and extent of ESS, low-volume surgeons (1-17/year) remained an independent statistically significant predictor of revision surgery (hazard ratios [HR]: 1.60, 95% confidence interval [CI]: 1.17-2.19). CONCLUSION:Our study is the first to demonstrate a surgeon volume-outcome relationship in ESS. Being a high-volume surgeon is predictive of a lower revision rate in CRS patients undergoing ESS.

OBJECTIVE:Recently, the endocannabinoid system (ECS) has emerged as a therapeutic target for various inflammatory diseases, including those of the respiratory tract. The objective of this scoping review is to explore the role of the ECS in the pathophysiology of CRS. Moreover, we sought to identify, appraise, and summarize the available evidence for cannabinoids as a potential treatment for CRS. DATA SOURCES:Six databases and four clinical trial registries were searched from inception to February 2025. REVIEW METHODS:All identified studies investigating the role of the ECS in sinonasal inflammatory disease were included for review. RESULTS:A total of 1534 studies were identified in the initial search. Following screening and full-text analysis by three authors, five studies were included in the final scoping review. Four of the studies were preclinical and in vitro in nature, examining the effects of ECS modulation through CB1 and/or CB2 receptors. The findings of each study support a common conclusion that the ECS is implicated in regulating cellular inflammatory pathways potentially involved in sinonasal disease. The final study investigated the effect of marijuana smoking on subjective and objective measures of CRS severity. There were no clinical studies identified investigating the use of cannabinoids for the treatment of sinonasal inflammatory conditions. CONCLUSION:Current literature examining the role of ECS in sinonasal inflammatory disease is highly limited, though it indicates ECS may play a role in the complex pathophysiology of sinonasal inflammatory disease. Further work is warranted to assess ECS as a potential therapeutic target for CRS.

BACKGROUND:Given the association between spontaneous cerebrospinal fluid (sCSF) leak and idiopathic intracranial hypertension (IIH), and the association of IIH and venous sinus stenosis (VSS), we sought to determine the prevalence of VSS in sCSF leak and the role of venous sinus stenting for sCSF leak. METHODS:A protocol was registered in PROSPERO [CRD42024568270]. A search was conducted in four electronic databases: Medline (Ovid), Embase, CINAHL, Web of Science, and Cochrane CENTRAL. Two reviewers independently screened citations and extracted data. Methodological quality was assessed using the Joanna Briggs Institute's critical appraisal tool. Data were pooled using a random effects model to calculate overall prevalence and relative risk (RR). RESULTS:Fifteen studies met the final inclusion criteria, with a total of 372 patients presenting with sCSF leak. The pooled prevalence of VSS in patients with sCSF leak was 0.71 (95% CI: 0.56-0.83, I2 = 74%). VSS was three-fold greater in patients with sCSF leak compared to those without, although this was not statistically significant (RR = 3.11; 95% CI: 0.64-15.27, I2 = 87%). Ninety percent of patients with VSS who underwent venous sinus stenting as adjunctive therapy to surgical repair of sCSF leak or for medically refractive IIH demonstrated resolution of symptoms without sCSF leak recurrence at last follow-up. CONCLUSION:VSS is common in patients with sCSF leak, and adjunctive venous sinus stenting after surgical leak repair may benefit a subset of patients. Further studies are needed to clarify the role of venous sinus stenting in conjunction with surgical repair of leaks.

Objective Health literacy is defined as the ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health. This study aimed to assess the health literacy of patients seeking care at an adult tertiary care Otolaryngology-Head and Neck Surgery (OHNS) clinic and its correlation with sociodemographic information. Study Design Prospective cross-sectional study. Setting Tertiary care OHNS clinic. Participants New adult patients who presented to a tertiary OHNS clinic from July 2022 to March 2023. Interventions Patients were asked to complete a sociodemographic questionnaire and the BRIEF Health Literacy Screening Tool. The BRIEF is scored out of 20 with scores of 17 and higher showing adequate health literacy. Main Outcome Measures Bivariate and multivariate analyses were performed to determine whether sociodemographic variables were associated with health literacy. Results Two hundred eighteen patients were recruited (59% females, 32% were above age 65). Although the average score on the BRIEF was 17.0 ± 3.6, about 33% of participants were found to have inadequate health literacy. Non-native English speakers, racial minorities, immigrants, and those with a lower income were more likely to have poor health literacy. Conclusion This study highlights that a significant number of patients presenting to a tertiary OHNS clinic have inadequate health literacy, with certain socioeconomic factors serving as predictors. Future research is needed to evaluate targeted interventions aimed at improving and advocating for health literacy among OHNS patients.

OBJECTIVE:To assess whether patients of advanced age with chronic rhinosinusitis (CRS) experience comparable symptom improvement and disease control following endoscopic sinus surgery (ESS) compared to younger patients. DATA SOURCES:Systematic searches were performed across PubMed, Embase, Web of Science, Scopus, and CENTRAL to May 2024. REVIEW METHODS:Following PRISMA guidelines, we included comparative studies with age-stratified cohorts reporting outcomes for CRS patients undergoing ESS. The primary outcome was symptom improvement measured by the 22-item Sinonasal Outcome Test (SNOT-22). Secondary outcomes were disease recurrence and revision rates. Meta-regression examined the influence of sex, preoperative symptom severity, nasal polyps, and prior ESS. RESULTS:Across the included studies, data from 3161 patients were analyzed. Advanced-age patients demonstrated significantly less SNOT-22 improvement than younger counterparts (SMD -0.36; 95% confidence interval [CI], -0.61 to -0.10; P = .01). Nevertheless, recurrence and revision rates were lower in the advanced-age group-12% and 3%, respectively-corresponding to a 50% reduction in combined risk (RR 0.50; 95% CI, 0.33-0.75; P < .001). Meta-regression identified male sex as a predictor of greater symptom improvement in advanced-age patients (β = 0.06, P = .03), whereas prior ESS was associated with diminished improvement (β = -0.05, P < .01). CONCLUSION:Patients of advanced age may experience less pronounced symptomatic improvement but lower recurrence and revision rates after ESS. These differences should be interpreted with caution, as they may reflect both surgical outcomes and other factors such as comorbidities or reoperation thresholds. Age alone should not preclude ESS, which remains an effective option when tailored to individual patient characteristics.

OBJECTIVE:To compare the outcomes of endoscopic sinus surgery (ESS) and dupilumab using nasal nitric oxide (nNO) as a biomarker of mucosal health, Lund-Kennedy endoscopy score (LKES), and Sino-Nasal Outcome Test-22 (SNOT-22). METHODS:A prospective observational cohort of chronic rhinosinusitis with nasal polyposis (CRSwNP) patients who underwent ESS followed by standard postoperative therapy was compared with another prospective cohort of CRSwNP patients who received dupilumab. In addition to baseline characteristics, nNO production, LKES, and SNOT-22 levels were compared between the 2 cohorts at the 1st month and 6th month posttreatment. RESULTS:A total of 28 and 37 patients were included in the ESS cohort and the dupilumab group, respectively. At the 1stmonth and 6th month posttreatment, nNO levels were comparable between 2 groups. Compared to baseline, the ESS cohort showed increased nNO levels at 1st month posttreatment, while the dupilumab group did not. At the 6th month posttreatment, both groups exhibited a significant increase in nNO levels. Similar trend was observed in LKES. SNOT-22 decreased at the 1st month and 6th month posttreatment compared with that in baseline. CONCLUSION:ESS and dupilumab confer comparable benefits in terms of nNO changes, symptoms, and endoscopy findings at the 6th month posttreatment. ESS may result in more rapid improvement in the outcomes than in dupilumab as evidenced by the 1 month posttreatment values.

Chronic rhinosinusitis (CRS) is diagnosed with symptoms and objective endoscopy or computed tomography (CT). The Lund–Mackay score (LMS) is often used to determine the radiologic severity of CRS and make clinical decisions. This proof-of-concept study aimed to develop an automated algorithm combining a convolutional neural network (CNN) for sinus segmentation with post-processing to compute LMS directly from CT scans. Radiology Information System was queried for outpatient paranasal sinus CTs at a tertiary institution. We identified 1,399 CT scans which were manually labelled with LMS of individual sinuses. Seventy-seven CT scans with 13,668 coronal images were segmented manually for individual sinuses. Our model for segmentation achieved a mean Dice score of 0.85 for all sinus regions, except for the osteomeatal complex. For individual Dice scores were 0.95, 0.71, 0.78, 0.93, 0.86 for the maxillary, anterior ethmoid, posterior ethmoid, sphenoid, and frontal sinuses, respectively. LMS was computed automatically by applying adaptive image thresholding and pixel counting to the CNN’s segmented regions. A convolutional neural network (CNN) model was trained to segment each sinus region. Overall, the LMS model showed a high degree of accuracy with a score of 0.92, 0.99, 0.99, 0.97, 0.99, 0.86 for the maxillary, anterior ethmoid, posterior ethmoid, sphenoid, and frontal sinuses, respectively. Reporting of paranasal sinus CT can be automated and potentially standardized with a CNN model to provide accurate Lund–Mackay score.

BACKGROUND:Type 2 biologics have been used increasingly for the treatment of chronic rhinosinusitis with nasal polyps (CRSwNP). However, patterns of biologic switching are understudied, and established guidelines for sequential or simultaneous use do not yet exist. METHODS:This is a Canadian multicenter retrospective study of real-world patient data. Patients were included if they had recurrent CRSwNP despite maximal medical and surgical management, and received at least one dose of a type 2 biologic. Patients who remained on their initial biologic comprised the continuous group. Patients with sequential or simultaneous use of more than one biologic comprised the switched group. We compared the characteristics of patients who continued and switched biologics. RESULTS:Note that 225 consecutive patients were included. Thirty-six (16%) switched biologics at least once, and six (3%) switched twice. The most common switch was from mepolizumab to dupilumab, with poor control of CRSwNP symptoms being the leading cause for this switch. Lack of efficacy was the main reason for switching off mepolizumab and omalizumab, while adverse events were the leading cause for switching off dupilumab. Additionally, mepolizumab patients were more likely to switch biologics late in their treatment, while dupilumab patients rarely switched after 12 months of therapy (p-value < 0.001). CONCLUSIONS:Switching biologics for CRSwNP is frequent in Canadian rhinology practices, with 16% of patients switching at least once. The most common switch is from mepolizumab to dupilumab with inadequate CRSwNP control driving this switch. This study may help guide sequential or simultaneous use of biologics in CRSwNP patients.

Vestibular schwannomas (VS) are the most common tumor of the skull base with available treatment options that carry a risk of iatrogenic injury to the facial nerve, which can significantly impact patients' quality of life. As facial nerve outcomes remain challenging to prognosticate, we endeavored to utilize machine learning to decipher predictive factors relevant to facial nerve outcomes following microsurgical resection of VS. A database of patient-, tumor- and surgery-specific features was constructed via retrospective chart review of 242 consecutive patients who underwent microsurgical resection of VS over a 7-year study period. This database was then used to train non-linear supervised machine learning classifiers to predict facial nerve preservation, defined as House-Brackmann (HB) I vs. facial nerve injury, defined as HB II-VI, as determined at 6-month outpatient follow-up. A random forest algorithm demonstrated 90.5% accuracy, 90% sensitivity and 90% specificity in facial nerve injury prognostication. A random variable (rv) was generated by randomly sampling a Gaussian distribution and used as a benchmark to compare the predictiveness of other features. This analysis revealed age, body mass index (BMI), case length and the tumor dimension representing tumor growth towards the brainstem as prognosticators of facial nerve injury. When validated via prospective assessment of facial nerve injury risk, this model demonstrated 84% accuracy. Here, we describe the development of a machine learning algorithm to predict the likelihood of facial nerve injury following microsurgical resection of VS. In addition to serving as a clinically applicable tool, this highlights the potential of machine learning to reveal non-linear relationships between variables which may have clinical value in prognostication of outcomes for high-risk surgical procedures.

OBJECTIVES:There is growing interest in assessing patient quality of life (QOL) following treatment of sinonasal tumors, including inverted papilloma (IP). We aimed to elucidate the natural history of postoperative QOL outcomes in IP patients treated with surgery. METHODS:Cases of sinonasal IP treated surgically at 4 tertiary academic rhinology centers were retrospectively reviewed. SNOT-22 scores were used to evaluate QOL preoperatively and postoperatively (1, 3, 6, 12 months). Repeated-measures ANOVA assessed for differences in mean scores over time. Linear regression identified factors associated with QOL longitudinally. RESULTS:373 patients were analyzed. Mean preoperative SNOT-22 score was 20.6 ± 20.4, which decreased to 16.3 ± 18.8 (p = 0.041) and 11.8 ± 15.0 (p < 0.001) at 1 and 3 months postoperatively, respectively. No further changes in SNOT-22 scores occurred beyond 3 months postoperatively (p > 0.05). When analyzed by SNOT-22 subdomains, nasal, sleep, and otologic/facial subdomain scores (all p < 0.05) demonstrated improvement at 12-month follow-up compared with preoperative scores; this was not observed for the emotional subdomain score (p = 0.800). Recurrent cases were associated with higher long-term SNOT-22 scores (β = 7.08; p = 0.017). Age, sex, degree of dysplasia, prior surgery, primary site, and smoking history did not correlate with symptoms (all p > 0.05). CONCLUSIONS:QOL outcomes related to IP resection are largely driven by nasal, sleep, and otologic/facial subdomains, though patients appear to experience enduring improvement as early as 3 months postoperatively. Recurrent disease is a major driver of negative QOL. LEVEL OF EVIDENCE:4 Laryngoscope, 135:579-585, 2025.

BACKGROUND:COVID-19 had a tremendous impact on surgical residency education and training. With little experience or training in using online learning in pedagogically informed ways, some surgical educators and learners experienced the disadvantages of online learning which may have contributed to a greater sense of burnout in the pandemic. The purpose of this study is to survey the level of burnout in surgical educators and assess educators' perspectives on factors that increased or decreased burnout in synchronous online teaching during the pandemic. METHODS:A cross-sectional study consisting of 4 sections was sent to surgical educators at the University of Toronto. Demographic data, validated surveys on burnout and videoconferencing fatigue (the Maslach Burnout Inventory-Educators Survey (MBI-ES) and the Zoom Exhaustion and Fatigue (ZEF) scale respectively), and quantitative questions about teaching factors in synchronous online environments were collected and analyzed. RESULTS:The MBI-ES demonstrated a high degree of emotional exhaustion, and depersonalization and a moderate degree of personal accomplishment in surgeon educators. The ZEF scale noted moderate fatigue across all domains. Although educators noted online learning to be a moderate factor contributing to burnout during the pandemic, there was no correlation between the number of hours or percentage of time teaching online to burnout or zoom fatigue scores. The largest reported contributing factor to online learning leading to burnout was lack of connection to learners, whereas the largest mitigating factor was decreased travel time. INTERPRETATIONS:The study found a moderate degree of exhaustion and burnout among surgical educators in Canada during COVID-19 and examined how aspects of online synchronous learning may have contributed to or helped mitigate these experiences. Based on this, we present approaches and educational theories to improve the online learning experience for surgical educators going forward.

This report analyzes traumatic anterior skull base CSF leaks following nasopharyngeal swab testing for detection of SARS-CoV-2 in the largest case series to date, combined with a systematic literature review. Retrospective multi-institutional case-series of traumatic anterior skull base CSF leak with clear antecedent history of COVID-19 swab was completed. A comprehensive search of databases was performed for the systematic literature review. Thirty-four patients with traumatic CSF leak after COVID-19 nasopharyngeal swab testing were identified. Women were more than twice as likely to experience a CSF leak, as compared to men. The majority of patients (58.8

Rationale: Injury to the internal carotid artery (ICA) is a serious and devastating complication for the skull base surgeon. It is an uncommon injury and therefore limited training is received in the management of this complication. Our group aimed to develop a simulation scenario of an ICA injury during endoscopic surgery based on the principles of developing skills related to crisis resource management and interprofessional/interdisciplinary team communication. A modified Delphi approach was previously used to develop a protocol for management of ICA injury known as the alert–control–transfer protocol and we sought to develop this algorithm into an educational simulation teaching tool for post-graduate residents.

BACKGROUND:Biologic therapies approved for treating chronic rhinosinusitis with nasal polyps (CRSwNP) have well-established safety profiles but reports of rheumatic adverse events (AEs) are increasing and not well defined. This review aims to assess the risk and incidence of rheumatic AEs associated with biologic therapy in CRSwNP and summarize current reported management strategies. METHODS:A protocol was registered in PROSPERO [CRD42024525663]. A search was conducted in four electronic databases: Medline (Ovid), Embase, Scopus, and Cochrane CENTRAL from inception until January 4, 2024. Two reviewers independently screened citations and extracted data. Methodological quality was assessed using the Joanna Briggs Institute's critical appraisal tool. Data were pooled using a random effects model to calculate overall incidence and relative risk. RESULTS:Twenty-one studies met the final inclusion criteria, totaling 3434 patients of which 2763 (80%) received either dupilumab (n = 2257; 82%), mepolizumab (n = 372; 13%), or omalizumab (n = 134; 5%) for treatment of CRSwNP. The overall incidence rate for any on-treatment rheumatic AE was 0.05 per person-year (95% CI, 0.03-0.09, I2 = 75%). Biologic therapy increased the risk of developing a rheumatic AE (RR = 2.53; 95% CI, 1.29-4.94) compared with placebo. The most frequently reported rheumatic AE was arthralgia or joint pain (n = 94; 95%), followed by lupus-like syndrome or lupus erythematosus-like reaction (n = 2; 2.5%). Discontinuation of treatment was the most common intervention (n = 21, 39%). CONCLUSION:Biologic therapy increases the risk of rheumatic AEs in CRSwNP patients by over twofold. Healthcare providers should remain vigilant in monitoring rheumatic AEs and apply appropriate management strategies on a case-by-case basis.