OBJECTIVES:Skull base osteomyelitis (SBO) is a rare infection comprising either the lateral (LSBO), central (CSBO), or both lateral and central (BSBO) skull base. Due to its rarity, the optimal length of antimicrobial therapy (AMT) has not been well defined. Therefore, the purpose of this study was to identify factors that may influence outcomes of SBO and formulate clearer recommendations on AMT duration. METHODS:A multi-institutional retrospective cohort study of SBO patients was conducted. Patient demographics, medical comorbidities, presenting symptoms, laboratory results, radiographic imaging, surgical treatment, culture results, length of follow-up, and type, length, and number of AMT courses were collected. RESULTS:Sixty-five patients were included. The average age was 66.5 years, and the average length of symptoms (LOS) prior to diagnosis was 3.74 months. The most common pathogen was Pseudomonas aeruginosa (n = 23) followed by coagulase-negative Staphylococcus species (n = 15). The average length of IV AMT was 6.8 weeks, and the average total length of AMT (TLA) was 15.7 weeks. Positive fungal cultures were associated with longer TLA (22.6 vs. 13.7 weeks, p = 0.02) and a greater number of distinct courses of AMT (4.1 vs. 2.7, p = 0.01). CONCLUSION:In this series, the average length of IV AMT was 6.8 weeks. The average TLA was 15.7 weeks, indicating that a minimum of 6 weeks of IV AMT followed by a prolonged course of oral AMT is necessary to treat most cases of SBO. Fungal involvement significantly impacts the duration of AMT. Clinical guidelines are needed to better define the management of this complex disease. LEVEL OF EVIDENCE: 4:

BACKGROUND:Nasal airway obstruction (NAO) is prevalent with substantial health and quality of life burdens. Nasal valve collapse (NVC) is one structural cause of NAO. Temperature-controlled radiofrequency (TCRF) nasal valve remodeling offers an alternative to invasive surgery. Clinical efficacy is established, but the impacts of TCRF on healthcare resource utilization (HRU) and cost in real-world settings remain underexplored. METHODS:Two cohorts with NAO were defined from a large general NAO population: the TCRF cohort with an isolated TCRF (index) procedure and a propensity-matched medically managed (MM) cohort without nasal procedures. HRU and costs were evaluated within a 24-month pre-/post-index period for both. RESULTS:A total of 10,206 TCRF and 50,766 MM patients were analyzed. Significant post-index reductions were observed for TCRF across all-cause Evaluation & Management (E&M) visits, ENT-related procedures, and sleep-related claim categories. A large reduction in mean daily post-index costs was seen for the TCRF cohort: $68.07 pre-index to $38.75 post-index (-43.1%). Mean daily costs went up in the MM cohort from $42.08 pre-index to $63.26 post-index (+50.4%), resulting in total cost savings of $21,418.26 for the TCRF cohort and a total cost increase of $15,471.99 in the MM cohort in the 24-month post-index period. TCRF cost reductions were driven by reductions in NAO-related HRU. CONCLUSIONS:In this large, real-world analysis, TCRF treatment for NVC-related NAO demonstrated substantial reductions in HRU and total costs of care, demonstrating sustained savings over 2 years relative to MM patients.

Technologic developments in a variety of instruments and tools have been integral in the development and advancement of endoscopic endonasal skull base surgery. From scopes and camera heads to imaging modalities and surgical navigation down to the very instruments necessary to safely and effectively perform these surgeries, it is fair to say that endonasal skull base surgery exists because of these technologic advancements. Although the list of the available technology includes several areas, this chapter focuses specifically on powered instrumentation and bipolar technology currently available for endonasal skull base surgery.

BackgroundSinonasal neoplasms, whether benign and malignant, pose a significant challenge to clinicians and represent a model area for multidisciplinary collaboration in order to optimize patient care. The International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors (ICSNT) aims to summarize the best available evidence and presents 48 thematic and histopathology-based topics spanning the field.MethodsIn accordance with prior International Consensus Statement on Allergy and Rhinology documents, ICSNT assigned each topic as an Evidence-Based Review with Recommendations, Evidence-Based Review, and Literature Review based on the level of evidence. An international group of multidisciplinary author teams were assembled for the topic reviews using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses format, and completed sections underwent a thorough and iterative consensus-building process. The final document underwent rigorous synthesis and review prior to publication.ResultsThe ICSNT document consists of four major sections: general principles, benign neoplasms and lesions, malignant neoplasms, and quality of life and surveillance. It covers 48 conceptual and/or histopathology-based topics relevant to sinonasal neoplasms and masses. Topics with a high level of evidence provided specific recommendations, while other areas summarized the current state of evidence. A final section highlights research opportunities and future directions, contributing to advancing knowledge and community intervention.ConclusionAs an embodiment of the multidisciplinary and collaborative model of care in sinonasal neoplasms and masses, ICSNT was designed as a comprehensive, international, and multidisciplinary collaborative endeavor. Its primary objective is to summarize the existing evidence in the field of sinonasal neoplasms and masses.

PURPOSE OF REVIEW:To review the various factors associated with the most common cause of maxillary sinus dysfunction; recalcitrant chronic maxillary sinusitis (RCMS). In addition, available medical and surgical management options are discussed along with various tips and tricks for optimal management.RECENT FINDINGS:Defects in mucociliary clearance, immunodeficiency, anatomic factors, and infectious etiologies have been implicated in dysfunction of the maxillary sinus leading to RCMS. Medical management including oral antibiotics or topical drugs have shown varying degrees of success. Endoscopic modified medial maxillectomy (EMMM) has been shown to significantly improve symptoms in patients with RCMS.SUMMARY:A dysfunctional maxillary sinus presents a clinical challenge. A thorough evaluation of any potential contributing factors must be done in addition to an assessment of the adequacy of prior surgical treatment of the maxillary sinus. Beyond the middle meatal antrostomy, EMMM can be used to effectively address RCMS. In cases that fail EMMM, removal of the condemned mucosa to encourage auto-obliteration of the sinus can be considered.

BACKGROUND:In the 5 years that have passed since the publication of the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR-Allergic Rhinitis 2018), the literature has expanded substantially. The ICAR-Allergic Rhinitis 2023 update presents 144 individual topics on allergic rhinitis (AR), expanded by over 40 topics from the 2018 document. Originally presented topics from 2018 have also been reviewed and updated. The executive summary highlights key evidence-based findings and recommendation from the full document. METHODS:ICAR-Allergic Rhinitis 2023 employed established evidence-based review with recommendation (EBRR) methodology to individually evaluate each topic. Stepwise iterative peer review and consensus was performed for each topic. The final document was then collated and includes the results of this work. RESULTS:ICAR-Allergic Rhinitis 2023 includes 10 major content areas and 144 individual topics related to AR. For a substantial proportion of topics included, an aggregate grade of evidence is presented, which is determined by collating the levels of evidence for each available study identified in the literature. For topics in which a diagnostic or therapeutic intervention is considered, a recommendation summary is presented, which considers the aggregate grade of evidence, benefit, harm, and cost. CONCLUSION:The ICAR-Allergic Rhinitis 2023 update provides a comprehensive evaluation of AR and the currently available evidence. It is this evidence that contributes to our current knowledge base and recommendations for patient evaluation and treatment.

SMARCB1(INI-1)-deficient sinonasal carcinoma is a rare, poorly differentiated neoplasm with a poor prognosis. Though historically most were identified as sinonasal undifferentiated carcinoma, we now understand it to be a distinct entity. There is currently a general consensus supporting multimodal therapy, though the optimal sequence of surgery, chemotherapy, and radiation has yet to be defined.

BACKGROUND:We identify chronic rhinosinusitis (CRS) manifestations associated with how rhinologists assess CRS control, with a focus on patient perspectives (patient-reported CRS control). METHODS:Fifteen rhinologists were provided with real-world data from 200 CRS patients. Participating rhinologists first classified patients' CRS control as "controlled," "partly controlled," and "uncontrolled" using seven CRS manifestations reflecting European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) CRS control criteria (nasal obstruction, drainage, impaired smell, facial pain/pressure, sleep disturbance, use of systemic antibiotics/corticosteroids in past 6 months, and nasal endoscopy findings) and patient-reported CRS control. They then classified patients' CRS control without knowledge of patient-reported CRS control. Interrater reliability and agreement of rhinologist-assessed CRS control with patient-reported CRS control and EPOS guidelines were determined. RESULTS:CRS control classification with and without knowledge of patient-reported CRS control was highly consistent across rhinologists (κw  = 0.758). Rhinologist-assessed CRS control agreed with patient-reported CRS control significantly better when rhinologists had knowledge of patient-reported CRS control (κw  = 0.736 vs. κw  = 0.554, p < 0.001). Patient-reported CRS control, nasal obstruction, drainage, and endoscopy findings were most strongly associated with rhinologists' assessment of CRS control. Rhinologists' CRS control assessments weakly agreed with EPOS CRS control guidelines with (κw  = 0.529) and without (κw  = 0.538) patient-reported CRS control. Rhinologists classified CRS as more controlled than EPOS guidelines in almost 50% of cases. CONCLUSIONS:This study directly demonstrates the importance of patient-reported CRS control as a dominant influence on rhinologists' CRS control assessment. Knowledge of patient-reported CRS control may better align rhinologists' CRS control assessments and treatment decisions with patients' perspectives.

BACKGROUND:Cystic fibrosis (CF) is a multisystem disease that often requires otolaryngology care. Individuals with CF commonly have chronic rhinosinusitis but also present with hearing loss and dysphonia. Given these manifestations of CF, otolaryngologists are frequently involved in the care of patients with CF; however, there is limited consensus on optimal management of sinonasal, otologic, and laryngologic symptoms. METHODS:The Cystic Fibrosis Foundation convened a multidisciplinary team of otolaryngologists, pulmonologists, audiologists, pharmacists, a social worker, a nurse coordinator, a respiratory therapist, two adults with CF, and a caregiver of a child with CF to develop consensus recommendations. Workgroups developed draft recommendation statements based on a systematic literature review, and a ≥80% consensus was required for acceptance of each recommendation statement. RESULTS:The committee voted on 25 statements. Eleven statements were adopted recommending a treatment or intervention, while five statements were formulated recommending against a specific treatment or intervention. The committee recommended eight statements as an option for select patients in certain circumstances, and one statement did not reach consensus. CONCLUSION:These multidisciplinary consensus recommendations will help providers navigate decisions related to otolaryngology consultation, medical and surgical management of CF-CRS, hearing, and voice in individuals with CF. A collaborative and multidisciplinary approach is advocated to best care for our patients with CF. Future clinical research is needed utilizing standardized, validated outcomes with comprehensive reporting of patient outcome, effects of modulator therapies, and genetic characteristics to help continue to advance care, decrease morbidity, and improve the quality of life for individuals with CF.

The surgical approach to lesions of the ventral craniovertebral junction (CVJ) has evolved significantly in the last several years with the advent of endoscopic skull base surgery. Differing pathologies of the CVJ can result in irreducible compression of the cervicomedullary region. The endoscopic endonasal approach lends itself well to this region due to the ventral location, and while there is a steep learning curve, is a safe and effective way to perform decompression of the cervicomedullary region. Herein, we discuss the anatomy of the CVJ, preoperative evaluation and surgical considerations, our surgical approach, complications, and outcomes.

International Forum of Allergy & RhinologyVolume 11, Issue 5 p. 941-945 RESEARCH NOTE Characterizing the complexity of frontal endoscopic sinus surgery: a multi-institutional, prospective, observational trial Philip G. Chen MD, Corresponding Author p_g_chen@hotmail.com orcid.org/0000-0002-5468-3324 Department of Otolaryngology–Head and Neck Surgery, University of Texas Health San Antonio, San Antonio, TX Correspondence to: Philip G. Chen, MD, Department of Otolaryngology–Head and Neck Surgery, University of Texas Health San Antonio, 7703 Floyd Curl Drive, MC 7777, San Antonio, TX 78229; e-mail: p_g_chen@hotmail.comSearch for more papers by this authorJoshua M. Levy MD, MPH, orcid.org/0000-0001-5907-3421 Department of Otolaryngology–Head and Neck Surgery, Emory University School of Medicine, Atlanta, GASearch for more papers by this authorGarret Choby MD, orcid.org/0000-0002-3745-2727 Department of Otolaryngology–Head and Neck Surgery, Mayo Clinic, Rochester, MNSearch for more papers by this authorKristine Smith MD, orcid.org/0000-0002-7026-5819 Department of Otolaryngology–Head and Neck Surgery, University of Manitoba, Winnipeg, MB, CanadaSearch for more papers by this authorWilliam C. Yao MD, orcid.org/0000-0002-9845-2165 Department of Otorhinolaryngology–Head and Neck Surgery, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TXSearch for more papers by this authorAshleigh Halderman MD, Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern, Dallas, TXSearch for more papers by this authorGretchen M. Oakley MD, Division of Otolaryngology–Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UTSearch for more papers by this authorJoseph Brunworth MD, Department of Otolaryngology–Head and Neck Surgery, St Louis University Hospital, St Louis, MOSearch for more papers by this authorJeremiah A. Alt MD, PhD, orcid.org/0000-0003-0560-5028 Division of Otolaryngology–Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UTSearch for more papers by this author Philip G. Chen MD, Corresponding Author p_g_chen@hotmail.com orcid.org/0000-0002-5468-3324 Department of Otolaryngology–Head and Neck Surgery, University of Texas Health San Antonio, San Antonio, TX Correspondence to: Philip G. Chen, MD, Department of Otolaryngology–Head and Neck Surgery, University of Texas Health San Antonio, 7703 Floyd Curl Drive, MC 7777, San Antonio, TX 78229; e-mail: p_g_chen@hotmail.comSearch for more papers by this authorJoshua M. Levy MD, MPH, orcid.org/0000-0001-5907-3421 Department of Otolaryngology–Head and Neck Surgery, Emory University School of Medicine, Atlanta, GASearch for more papers by this authorGarret Choby MD, orcid.org/0000-0002-3745-2727 Department of Otolaryngology–Head and Neck Surgery, Mayo Clinic, Rochester, MNSearch for more papers by this authorKristine Smith MD, orcid.org/0000-0002-7026-5819 Department of Otolaryngology–Head and Neck Surgery, University of Manitoba, Winnipeg, MB, CanadaSearch for more papers by this authorWilliam C. Yao MD, orcid.org/0000-0002-9845-2165 Department of Otorhinolaryngology–Head and Neck Surgery, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TXSearch for more papers by this authorAshleigh Halderman MD, Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern, Dallas, TXSearch for more papers by this authorGretchen M. Oakley MD, Division of Otolaryngology–Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UTSearch for more papers by this authorJoseph Brunworth MD, Department of Otolaryngology–Head and Neck Surgery, St Louis University Hospital, St Louis, MOSearch for more papers by this authorJeremiah A. Alt MD, PhD, orcid.org/0000-0003-0560-5028 Division of Otolaryngology–Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UTSearch for more papers by this author First published: 04 December 2020 https://doi.org/10.1002/alr.22746 Funding sources for the study: National Center for Advancing Translational Sciences of the National Institutes of Health (UL1TR002378 and KL2TR002381 to J.M.L.); National Heart Lung and Blood Institute (U54 HL-143541-02S2 to J.M.L.); National Institute on Deafness and Other Communication Disorders (R01 DC005805 to J.A.A.); National Institute of Allergy and Infectious Diseases (R44AI126987 to J.A.A.). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Potential conflicts of interest: J.A.A.: Medtronic, Novartis, and Optinose, consultant; affiliation with GlycoMira Therapeutics, Inc (none associated with this study). P.G.C.: Stryker, Integra, and Medtronic, consultant (not associated with this study). G.C.: Tissium LLC and Intersect ENT, consultant (not associated with this study). J.M.L.: AstraZeneca and Regeneron, consultant (not associated with this study). K.A.S.: Sanofi Genzyme, consultant (not associated with this study). W.Y.: Stryker, consultant; OptiNose US, speakers’ bureau (not associated with this study). The remaining authors have no conflicts of interest to disclose. 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 onEmailFacebookTwitterLinked InRedditWechat Volume11, Issue5May 2021Pages 941-945 RelatedInformation

BACKGROUND:A recent analysis suggested potential narrowing of the gender gap in research productivity in the field of rhinology. This analysis did not, however, provide insight into how the genders are represented in the rhinologic literature. This study aimed to evaluate 11 years of literature to evaluate for gender differences in authorship position, collaborations, category and content of research, citations, and funding to gain perspective on how gender and authorship has changed over time.METHODS:Authorship data for all articles on rhinologic subject matter published between January 1, 2008 and December 31, 2018 in four otolaryngology journals was collected. The gender of authors was determined by protocol. Category and content of research and funding status/source were additionally obtained.RESULTS:Data were collected from 2666 articles. Gender of 14,510 authors was determined. Female authors accounted for 23% of the overall authors and male authors accounted for 77%. Female first authorship increased significantly over time, but there was no change in female senior authorship. The percentage of female authors steadily increased over time, whereas male authorship decreased slightly. Mixed gender teams were shown to be increasing in frequency. Women published more than expected in basic science and allergy and less than expected in skull base. On funded studies, women were significantly underrepresented as senior authors.CONCLUSION:This study represents the first assessment of gender differences in the rhinology literature. Areas where female representation can improve include senior authorship, increased involvement in skull base publications, and increased funding.

The term fibro-osseous lesion applies to a broad range of pathologic conditions in which bone is replaced with a connective tissue matrix. The majority of these conditions are benign, but osteosarcoma, a malignant lesion, can also be categorized as a fibro-osseous lesion. The orbit and optic canal are rarely affected by such lesions in isolation, but rather are involved by the close proximity of the orbital complex with the paranasal sinuses and skull base. The most common fibro-osseous lesions observed in the craniofacial region, which are generally amenable to endoscopic or combined endoscopic and open surgical procedures, are reviewed in this chapter, including osteoma, osteoblastoma, osteoclastoma, ossifying fibroma, fibrous dysplasia, and osteosarcoma. Clinical and radiographic presentation of each condition along with treatment approaches and recommendations are discussed.

First described in the literature in 2012, biphenotypic sinonasal sarcoma represents a newly recognized neoplastic entity of the sinonasal cavities. As such, differential diagnosis of sinonasal masses may overlook this rare neoplasm. We present a case report of biphenotypic sinonasal sarcoma of the left ethmoid skull base and review the literature to better define the typical presentation, histologic appearance, and treatment outcomes of this rare tumor.

Introduction: Recurrent pituitary adenomas are challenging lesions. The typical second-line treatment is radiotherapy. Stereotactic radiosurgery and fractionated external beam radiotherapy are the modalities of choice. Pituitary adenomas refractory to photon radiation present a challenging clinical dilemma. There is no strong evidence to support a standard third-line therapy. At our institution, in select cases, we utilize brachytherapy as the third-line treatment option. We present our experience with the use of brachytherapy with I-125 seeds for multiple recurrent pituitary adenomas.