Case report: Side-firing intraoperative ultrasound guided endoscopic endonasal resection of a clival chordoma.

Clival chordomas are locally invasive midline skull base tumors arising from remnants of the primitive notochord. Intracranial vasculature and cranial nerve involvement of tumors in the paraclival region necessitates image guidance that provides accurate real-time feedback during resection. Several intraoperative image guidance modalities have been introduced as adjuncts to endoscopic endonasal surgery, including stereotactic neuronavigation, intraoperative ultrasound, intraoperative MRI, and intraoperative CT. Gross total resection of chordomas is associated with a lower recurrence rate; therefore, intraoperative imaging may improve long-term outcomes by enhancing the extent of resection. However, among these options, effectiveness and accessibility vary between institutions. We previously published the first use of an end-firing probe in the resection of a clival chordoma. End-firing probes provide a single field of view, primarily limited to depth estimation. In this case report, we discuss the benefits of employing a novel minimally invasive side-firing ultrasound probe as a cost-effective and time-efficient option to navigate the anatomy of the paraclival region and guide endoscopic endonasal resection of a large complex clival chordoma.

Side-Firing Intraoperative Ultrasonograhy for Resection of Giant Pituitary Adenomas.

BACKGROUND: Suprasellar extension, cavernous sinus invasion, and involvement of intracranial vascular structures and cranial nerves are among the challenges faced by surgeons operating on giant pituitary macroadenomas. Intraoperative tissue shifts may render neuronavigation techniques inaccurate. Intraoperative magnetic resonance imaging can solve this problem, but it may be costly and time consuming. However, intraoperative ultrasonography (IOUS) allows for quick, real-time feedback and may be particularly useful when facing giant invasive adenomas. Here, we present the first study examining technique for IOUS-guided resection specifically focusing on giant pituitary adenomas. OBJECTIVE: To describe the use of a side-firing ultrasound probe in the resection of giant pituitary macroadenomas. METHODS: We describe an operative technique using a side-firing ultrasound probe (Fujifilm/Hitachi) to identify the diaphragma sellae, confirm optic chiasm decompression, identify vascular structures related to tumor invasion, and maximize extent of resection in giant pituitary macroadenomas. RESULTS: Side-firing IOUS allows for identification of the diaphragma sellae to help prevent intraoperative cerebrospinal fluid leak and maximize extent of resection. Side-firing IOUS also aids in confirmation of decompression of the optic chiasm via identification of a patent chiasmatic cistern. Furthermore, direct identification of the cavernous and supraclinoid internal carotid arteries and arterial branches is achieved when resecting tumors with significant parasellar and suprasellar extension. CONCLUSIONS: We describe an operative technique in which side-firing IOUS may assist in maximizing extent of resection and protecting vital structures during surgery for giant pituitary adenomas. Use of this technology may be particularly valuable in settings in which intraoperative magnetic resonance imaging is not available.

Side-firing intraoperative ultrasound applied to resection of pituitary macroadenomas and giant adenomas: A single-center retrospective case-control study.

Introduction: Multiple intraoperative navigation and imaging modalities are currently available as an adjunct to endoscopic transsphenoidal resection of pituitary adenomas, including intraoperative CT and MRI, fluorescence guidance, and neuronavigation. However, these imaging techniques have several limitations, including intraoperative tissue shift, lack of availability in some centers, and the increased cost and time associated with their use. The side-firing intraoperative ultrasound (IOUS) probe is a relatively new technology in endoscopic endonasal surgery that may help overcome these obstacles. Methods: A retrospective analysis was performed on patients admitted for resection of pituitary adenomas by a single surgeon at the University of Mississippi Medical Center. The control (non-ultrasound) group consisted of twelve (n=12) patients who received surgery without IOUS guidance, and the IOUS group was composed of fifteen (n=15) patients who underwent IOUS-guided surgery. Outcome measures used to assess the side-firing IOUS were the extent of tumor resection, postoperative complications, length of hospital stay (LOS) in days, operative time, and self-reported surgeon confidence in estimating the extent of resection intraoperatively. Results: Preoperative data analysis showed no significant differences in patient demographics or presenting symptoms between the two groups. Postoperative data revealed no significant difference in the rate of gross total resection between the groups (p = 0.716). Compared to the non-US group, surgeon confidence was significantly higher (p < 0.001), and operative time was significantly lower for the US group in univariate analysis (p = 0.011). Multivariate analysis accounting for tumor size, surgeon confidence, and operative time confirmed these findings. Interestingly, we noted a trend for a lower incidence of postoperative diabetes insipidus in the US group, although this did not quite reach our threshold for statistical significance. Conclusion: Incorporating IOUS as an aid for endonasal resection of pituitary adenomas provides real-time image guidance that increases surgeon confidence in intraoperative assessment of the extent of resection and decreases operative time without posing additional risk to the patient. Additionally, we identified a trend for reduced diabetes insipidus with IOUS.

Feasibility of Implementing Opioid Stewardship Recommendations for Sinonasal Surgery.

OBJECTIVE: The objective of our study was to review the current literature pertaining to perioperative opioids in sinus surgery and to determine the effects of implementing opioid stewardship recommendations in the setting of endoscopic sinonasal surgery. STUDY DESIGN: Single-institution retrospective case-control study. SETTING: Academic medical center outpatient area. METHODS: This retrospective review comprised 163 patients who underwent routine functional endoscopic sinus surgery, septoplasty, and/or inferior turbinate reduction before and after implementation of a standardized pain control regimen based on published opioid stewardship recommendations. The regimen consisted of an oral dose of gabapentin (400 mg) and acetaminophen (1000 mg) at least 30 minutes prior to surgery, absorbable nasal packing soaked in 0.5% tetracaine intraoperatively, and a postoperative regimen of acetaminophen and nonsteroidal anti-inflammatory medications. Tramadol tablets (50 mg) were prescribed postoperatively for breakthrough pain. The primary outcome measure for the study was the average number of hydrocodone equivalents (5 mg) prescribed before and after the new protocol. RESULTS: The average number of opioid medications prescribed, measured as hydrocodone equivalents (5 mg), decreased from 24.59 preprotocol to 18.08 after the initiation of the new perioperative regimen (P < .001). There was no significant difference between the periods (P > .05) in number of postoperative phone calls regarding pain or in patient satisfaction scores. CONCLUSION: Opioid stewardship recommendations can be instituted for sinonasal surgery, including multimodal perioperative pain management and substitution of tramadol for breakthrough pain, as a method to decrease the volume of opioids prescribed, without increasing patient phone calls or affecting the likelihood of physician recommendation Press Ganey scores.

Is weight a predictive risk factor of postoperative tonsillectomy bleed?

OBJECTIVE: To determine if a correlation exists between weight-for-age percentile and post-tonsillectomy hemorrhage in the pediatric population. STUDY DESIGN: Retrospective study. METHODS: 1418 patients under the age of 15 who underwent tonsillectomy with or without adenoidectomy at a tertiary children's hospital between June 2012 and March 2015 were included in this retrospective study. Patient demographic information, operative and postoperative variables, as well as category and day of postoperative tonsillectomy bleed, if one occurred, were recorded. Fisher's exact and ordinal logistic regression analyses were performed on the full cohort. RESULTS: The overall post-tonsillectomy hemorrhage prevalence was found to be 2.2%, with primary and secondary rates of 0.78% and 1.34%, respectively. Weight-for-age percentile, sex, indication for or method of tonsillectomy, or postoperative use of NSAIDs, antibiotics or narcotics were not significantly associated with post-tonsillectomy hemorrhage. There was a significant relationship between postoperative use of dexamethasone and higher rate of Category 3 post-tonsillectomy hemorrhage (P = .028). CONCLUSION: The post-tonsillectomy hemorrhage rate in our study is consistent with that cited in the literature. No correlation was demonstrated between weight-for-age percentile and occurrence of post-tonsillectomy hemorrhage. Postoperative administration of dexamethasone was associated with a significant increased rate of post-tonsillectomy hemorrhage requiring surgical intervention, a novel finding. LEVEL OF EVIDENCE: 4.

Cost-effectiveness of sialendoscopy versus medical management for radioiodine-induced sialadenitis.

OBJECTIVES/HYPOTHESIS: The medical management and radiographic identification of radioiodine-induced sialadenitis (RAIS) is challenging. This study utilizes a cost-effectiveness analysis to compare upfront sialendoscopy as both a diagnostic and therapeutic option versus multiple modalities of diagnostic radiography along with medical management. STUDY DESIGN: Literature review and cost-effectiveness analysis. METHODS: A literature review was performed to identify the outcomes of medical management, sialendoscopy, diagnostic radiography, and surgical complications. All charges were obtained from the University of Mississippi Budget Office in 2017 US dollars and converted to costs using the 2017 Medicare Cost-to-Charge Ratio for urban medical centers. A cost-effectiveness analysis was used to evaluate the four treatment arms-sialendoscopy, medical management- ultrasound, medical management-computed tomography (CT) sialography, and medical management-magnetic resonance (MR) sialography. Sensitivity analyses were used to evaluate the confidence levels of the economic evaluation. RESULTS: The incremental cost-effectiveness ratio for upfront sialendoscopy versus medical management-ultrasound was $30,402.30, which demonstrates that sialendoscopy is the more cost-effective option given a willingness-to-pay threshold of $50,000. The probability that this decision is correct at a willingness-to-pay of $50,000 is 64.5%. Sialendoscopic improvement was the most sensitive variable requiring a threshold of 0.70. Of the three imaging modalities, ultrasound dominated MR and CT sialography, both of which required a willingness-to-pay of greater than $90,000 to realize a difference. CONCLUSIONS: Upfront sialendoscopy is more cost-effective compared to medical management utilizing diagnostic ultrasound assuming a willingness-to-pay threshold of $50,000. There is a clear cost-effectiveness to using ultrasound with medical management over CT and MR sialography in the diagnosis and management of RAIS. LEVEL OF EVIDENCE: NA. Laryngoscope, 1822-1828, 2018.

Are prophylactic systemic antibiotics necessary with nasal packing? A systematic review.

BACKGROUND: The use of prophylactic systemic antibiotics with nasal packing has been a controversial topic. There are few evidence-based studies to determine the need for prophylactic systemic antibiotics. We performed a systematic literature review to determine the role of prophylactic systemic antibiotics with nasal packing in the prevention of toxic shock syndrome and local nasal infections. OBJECTIVE: The purpose of this study was to perform a systematic literature review to determine the role of prophylactic systemic antibiotics with nasal packing in the prevention of toxic shock syndrome and local nasal infections. METHODS: A search for studies that reviewed the efficacy of prophylactic systemic antibiotics in the prevention of toxic shock or nasal infections and/or sinusitis for patients with nasal packing for epistaxis and postoperative septoplasties was performed. This was conducted in a number of medical literature data bases by following the methods of the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Only English publications and human studies that were randomized control trials, quasi-randomized control trials, controlled clinical trials, retrospective studies, and case series were included. RESULTS: Six studies, with a total of 990 patients, met the inclusion criteria for the review and were included. Primary outcomes were signs and symptoms of nasal or sinus infections in patients who underwent nasal packing for epistaxis or septoplasty. There were no reports of toxic shock syndrome in any patients, and there was no statistical difference in purulent drainage in patients who had septoplasty (9.9 versus 11.2%) treated with or without antibiotics. CONCLUSION: There is a paucity of literature that reviewed the need for prophylactic systemic antibiotics with nasal packing. The available literature does not show a significant benefit to the use of antibiotics with nasal packing, but the studies were underpowered to detect such a difference. One must consider the associated risks of prophylactic antibiotics to the patient as well when deciding to prescribe prophylactic antibiotics.

Correlation of frontal sinus recess anatomy with ethnicity, gender, and pathology.

PURPOSE: Research on frontal sinus cells has been conflicting regarding relationship between frontal sinus cells and frontal sinus disease. There are no published studies regarding gender differences in frontal sinus disease. No comparisons between African Americans and Caucasians and frontal sinus disease have been published. This study attempts to define the above relationships as well as the relationship between number and types of cells and disease. METHODS: A retrospective chart review was performed on sinus CT scans done from 2003 to 2011 at an academic medical center. Exclusion criteria included previous frontal sinus surgery, sinus malignancy, obvious trauma, congenital anomalies, and poor quality of scan. Number and type of frontal cells were recorded for 602 scans. Statistical analysis performed demographic comparisons and compared number and types of cells to evidence of disease. RESULTS: Males were more likely than females to have frontal sinus disease. Patients with Type 3 and Type 4 cells were more likely to have disease. No significant ethnic related differences in disease were found using a multivariate logistic regression model. Total number of cells did not significantly affect likelihood of disease. CONCLUSIONS: This is one of the largest collections of data on frontal sinus cells as predictors of frontal sinus disease. These results suggest that gender and certain types of cells affect likelihood of disease. This study is the first to demonstrate a lack of difference in disease in African Americans and Caucasians. These results are significant regarding gender, race, number and type of cells as predictors of disease.

Strategies for decreasing contamination of homemade nasal saline irrigation solutions.

BACKGROUND: Saline nasal irrigations (SNI) are an important adjunct in the treatment of rhinosinusitis, and many patients prepare and store these solutions in their homes without an awareness of the potential for contamination. The objectives of this study were to determine if such contamination occurs and the effect of preparation methods on contamination. METHODS: Stock solutions of various tonicities and pHs were prepared using boiled, bottled, and distilled water (n = 57). The solutions were stored at ambient temperature or refrigerated for 1 week. Each day, 50 mL of the solutions were decanted to simulate transferring the stock solution into an irrigation vector. Cultures of the stock solutions were taken on days 1, 3, and 7. RESULTS: Overall contamination rate was 35.1%. The boiled water solutions were more likely to demonstrate bacterial growth (p < 0.001), as were those that were hypotonic (p = 0.046). pH had no significant effect (p = 0.127). Growth occurred as early as 24 hours after solution preparation. Pathogenic species isolated were Staphylococcus aureus, Moraxella sp, Sphingomonas paucimobilis, Acinetobacter junii, Methylobacterium sp, and Brevundimonas diminuta. No bacterial growth occurred in refrigerated solutions (p = 0.008). CONCLUSION: Pathogenic bacterial growth can occur in a short period of time in homemade SNI solutions with routine handling. Solutions should be refrigerated if possible. If solutions are to be stored at ambient temperature, they should be either isotonic or hypertonic and prepared from bottled or distilled water.

Clinical Consensus Statement: Septoplasty with or without Inferior Turbinate Reduction.

OBJECTIVE: To develop a clinical consensus statement on septoplasty with or without inferior turbinate reduction. METHODS: An expert panel of otolaryngologists with no relevant conflicts of interest was assembled to represent general otolaryngology and relevant subspecialty societies. A working definition of septoplasty with or without inferior turbinate reduction and the scope of pertinent otolaryngologic practice were first established. Patients 18 years and older were defined as the targeted population of interest. A modified Delphi method was then used to distill expert opinion into clinical statements that met a standardized definition of consensus. RESULTS: The group defined nasal septoplasty as a surgical procedure designed to correct a deviated nasal septum for the purpose of improving nasal function, form, or both. After 2 iterative Delphi method surveys, 20 statements met the standardized definition of consensus, while 13 statements did not. The clinical statements were grouped into 8 categories for presentation and discussion: (1) definition and diagnosis, (2) imaging studies, (3) medical management prior to septoplasty, (4) perioperative management, (5) surgical considerations, (6) adjuvant procedures, (7) postoperative care, and (8) outcomes. CONCLUSION: This clinical consensus statement was developed by and for otolaryngologists and is intended to promote appropriate and, when possible, evidence-based care for patients undergoing septoplasty with or without inferior turbinate reduction. A complete definition of septoplasty with or without inferior turbinate reduction was first developed, and additional statements were subsequently produced and evaluated addressing diagnosis, medical management prior to septoplasty, and surgical considerations, as well as the appropriate role of perioperative, postoperative, and adjuvant procedures, in addition to outcomes. Additionally, a series of clinical statements were developed, such as "Computed tomography scan may not accurately demonstrate the degree of septal deviation," "Septoplasty can assist delivery of intranasal medications to the nasal cavity," "Endoscopy can be used to improve visualization of posterior-based septal deviation during septoplasty," and "Quilting sutures can obviate the need for nasal packing after septoplasty." It is anticipated that the application of these principles will result in decreased variations in the care of septoplasty patients and an increase in the quality of care.

Clival chordoma of the nasal septum secondary to surgical pathway seeding.

EDUCATIONAL OBJECTIVE: At the conclusion of this presentation, the participants should be able to recognize seeding as a form of treatment failure in transseptal resection of clival chordomas. OBJECTIVES: The purpose is to present a case of implanted metastases in the nasal septum after a transseptal approach for resection of clival chordoma and to compare it with other reported cases in the literature. STUDY DESIGN: Case report and literature review. METHODS: The clinical history, radiologic imaging, and pathology of a single patient are reviewed. RESULTS: A 35-year-old female presented with a left intranasal mass that completely occluded the left nasal passage. The patient had a history of clival chordoma treated at an outside institution with multiple partial resections via a transseptal approach and postoperative Gamma Knife radiotherapy. A 2.5 cm mass in the left nasal cavity as well as a 4 cm sellar mass was identified on MRI. Biopsy of the left nasal mass confirmed the diagnosis of chordoma, which was presumed to be secondary to seeding from a previous resection attempt. The patient received no further treatment due to multiple comorbidities. CONCLUSIONS: Recurrence of clival chordoma due to seeding along the surgical pathway is an infrequent mechanism of treatment failure, with only rare cases documented in the literature. When deciding on the appropriate surgical approach, the surgeon must consider the risk of septal seeding during a transseptal approach. The emergence of transnasal endoscopic skull base approaches may reduce the likelihood of surgical pathway tumor seeding.

Atrophic rhinosinusitis: progress toward explanation of an unsolved medical mystery.

PURPOSE OF REVIEW: Atrophic rhinosinusitis is a chronic condition associated with considerable morbidity and decreased quality of life. This review describes progress in the characterization of primary and secondary atrophic rhinosinusitis and the development of diagnostic criteria for both syndromes. RECENT FINDINGS: Primary atrophic rhinitis usually develops as a consequence of an acute febrile illness in members of lower socioeconomic groups in developing areas of the world. The clinical setting and presence of culturable Klebsialla ozenae in the purulent, foul-smelling, nasal discharge of these patients forms the basis for diagnosis. An animal model for the disease exists in swine in which case an effective vaccine has been developed. Secondary atrophic rhinosinusitis is a condition that follows destruction of the nasal mucosa by any of a number of inflammatory processes including inflammatory diseases nasal/sinus surgery, and antiangiogenic therapy. Diagnostic criteria include patient reported recurrent epistaxis or episodic anosmia; or physician documented nasal purulence, nasal crusting, chronic inflammatory disease involving the upper airway (e.g. sarcoidosis, Wegener's granulomatosis, etc.) or two or more sinus surgeries. Patients with two more of these have secondary atrophic rhinitis with a sensitivity of 0.95 and a specificity of 0.77. SUMMARY: Atrophic rhinosinusitis results from destruction of the normal respiratory epithelium and transition to a nonciliated squamous epithelium, loss of mucociliary clearance, accumulation of stagnant mucous. That milieu facilitates acute and chronic infection (wet phase), and eventual sclerosis with epistaxis and chronic bloody crusts (dry phase).

Going to the next level: health care's evolving expectations for evidence.

Rhinologic literature has historically relied on lower levels of evidence to make prescriptive recommendations for use of new technology and procedures. However, as the medical profession has moved to embrace the principles of evidence-based medicine, expectations for minimum standards of evidence have risen. The resulting high-quality efficacy outcomes data have become the linchpin of informed decision making by physicians, payers, and health care systems. While many challenges remain in this transition to higher evidence expectations, none are insurmountable. It has become the responsibility of the organized medical profession to play a role in influencing and supporting production of high-quality outcomes research.

Diagnostic criteria for atrophic rhinosinusitis.

BACKGROUND: Patients with atrophic rhinosinusitis have intractable upper airway symptoms that result from loss of the normal nasal epithelium. There is no consensus on how to diagnose this condition, and diagnostic criteria are not available to perform multicenter treatment trials. We sought to establish diagnostic criteria for atrophic rhinosinusitis. METHODS: Twenty-two patients for whom there was a consensus on the diagnosis of atrophic rhinosinusitis were compared with a control group of 22 randomly selected patients with garden-variety chronic rhinosinusitis. Medical records were reviewed on all patients and clinical data were tabulated. Clinical variables included the presence of nasal obstruction, epistaxis, anosmia, purulence, crusting, chronic inflammatory disease involving the upper airway, and multiple sinus surgeries. RESULTS: Both groups had similar degrees of persistent nasal obstruction (82% vs 77%). The other 6 clinical features occurred more frequently in patients with atrophic rhinosinusitis than controls (P <.05). Patients with chronic rhinosinusitis and recurrent nasal purulence had a 25-fold (95% confidence interval [CI], 2.9-221.7) increased probability, those with recurrent epistaxis had a 12-fold increased probability (95% CI, 1.3-106.8), and those with 2 or more sinus surgeries had a 15-fold (95% CI, 3.5-66.7) increased probability of having atrophic rhinosinusitis. As the number of symptoms increased, there was an increasing probability of the predetermined diagnosis of atrophic rhinosinusitis (P <.05). The presence of chronic rhinosinusitis and any 2 of the 6 clinical features for 6 months or longer resulted in a sensitivity of 0.95 and specificity of 0.77 for the diagnosis of atrophic rhinosinusitis. CONCLUSION: The diagnosis of the common secondary form of atrophic rhinosinusitis may be made with certainty if a patient with chronic rhinosinusitis demonstrates 2 or more clinical features for 6 months and longer. These features are patient-reported recurrent epistaxis or episodic anosmia; or physician-documented nasal purulence, nasal crusting, chronic inflammatory disease of the upper airway, or 2 or more sinus surgeries.

Diagnostic evaluation of inhalant allergies: a cost-effectiveness analysis.

BACKGROUND: The purpose of this study was to compare the cost-effectiveness of modified quantitative testing (MQT), intradermal dilutional testing (IDT), and in vitro allergy testing as diagnostic methods used in the management of patients with suspected IgE-mediated inhalant allergies. METHODS: A systematic review was conducted to determine key statistics for analysis, such as prevalence of disease, and sensitivity and specificity of each diagnostic modality. Costs were calculated based on charges from distribution companies to providers. A deterministic cost-effectiveness analysis then was conducted using a decision tree model to evaluate the various diagnostic strategies. After identifying results at baseline, we performed a sensitivity and threshold analysis to assess the strength of recommendations. RESULTS: At an allergic rhinitis prevalence of 20%, MQT dominated IDT and in vitro testing, with 85 people correctly diagnosed at a baseline total cost of $6630 for the 100 patients tested. Although in vitro testing had the highest effectiveness, it had an incremental cost-effectiveness ratio of $3185. The results were sensitive to changes in the prevalence, costs, and sensitivities and specificities of the different modalities. CONCLUSION: The prevalence of allergic rhinitis is high and rising according to many studies, leading to a growing population of patients requiring allergy testing. Not only does today's medical community want effective health interventions, but also there is pressure to make health care cost efficient. This study looks at the cost-effectiveness of various diagnostic allergy tests. In our model, we found MQT to be the most cost-effective method of diagnosing allergic disease.

The evolution of surgical training: perspectives on educational models from the past to the future.

Surgical education and training have progressed through the centuries, with the most commonly used model being the apprentice model. With advances in medical knowledge and practice, the apprentice model has evolved and competing models have arisen. However, the apprentice model remains the gold standard today, but for future use, further evolutionary changes will need to be made to the apprentice model if it is to continue to remain an effective education paradigm.

Evidence-based recommendations for antimicrobial nasal washes in chronic rhinosinusitis.

BACKGROUND: Chronic rhinosinusitis (CRS) refractory to medical and surgical therapy is a difficult problem for patients and physicians. Topical antimicrobial nasal irrigations are commonly used for treatment with great variation in methodology and without clear scientific support for current treatment formulations. The purpose of this study was to develop a scientific rationale for creating standardized recommendations for clinical practice in the use of topical antimicrobial washes for CRS. METHODS: An extensive review of basic science and clinical literature on the treatment of CRS with topical antimicrobial washes was completed. Pharmacokinetics of and organism susceptibility to appropriate topically applied antimicrobial agents were reviewed. RESULTS: The most common organisms associated with CRS were identified. The relevant pharmacokinetics of drugs targeted at these organisms are presented. Susceptibility breakpoints set by the National Committee for Clinical Laboratory Standards are identified to help establish the most effective concentration of the identified drugs. Recommendations for agent selection, agent concentration, length of treatment, dosing schedule, and methods of irrigation are presented. CONCLUSION: Antimicrobial nasal washes provide a potentially effective treatment for the growing population of patients who remain symptomatic after appropriate medical and surgical intervention. This study establishes the basic principles supporting this treatment option and offers rational, evidence-based treatment guidelines. The study has identified additional areas that need to be investigated before prospective clinical trials can be effectively undertaken.

Economic analysis of the use of limited coronal computed tomography scans in the management of sinusitis.

BACKGROUND: As medical costs increase, less expensive alternatives to standard diagnostic tests are sought to reduce the economic burden placed on society. One alternative is using limited, non-consecutive cut computed tomography (CT) scans for the evaluation of sinonasal disease. This study evaluates the cost-effectiveness of using limited CT scans instead of full sequence CT scans in the diagnosis and management of rhinosinusitis. METHODS: A Medline search was performed to obtain data for the sensitivity and specificity of limited CT scans, the prevalence of abnormal CT scans, and recommendations on using limited CT scans for operative management. A standard cost-effectiveness analysis, including a sensitivity analysis, was performed using a hypothetical population of patients with sinus complaints who failed prior appropriate medical therapy. RESULTS: At baseline, the limited CT scan was found to be less cost-effective than the full CT scan, costing $217.13 more per correct diagnosis. The sensitivity analysis demonstrated that changes in the prevalence of abnormal CT scans and the percentage of surgeons who would operate using a limited scan had the greatest impact on cost, whereas changes in the price of the full CT or limited CT scan had the least effect. CONCLUSIONS: This study finds the use of limited CT scans to be economically unsound as a method to reduce costs in the defined population. Published literature recommends obtaining a full CT scan before operative management. Basing intervention on limited CT scans increases the possibility of erroneous diagnoses leading to either excessive or inadequate treatment of patients.

Utility of image guided surgery in the diagnosis of pterygopalatine fossa lesions.

OBJECTIVES: To describe the utility of image guided surgery in the diagnosis of pterygopalatine fossa lesions and to discuss the varied pathologic diagnoses from this area. STUDY DESIGN: Case series presentation. METHODS: Three cases of pterygopalatine fossa lesions were accessed and biopsied by way of a middle meatus antrostomy approach into the pterygopalatine fossa under image guidance for rapid localization. RESULTS: The diagnoses of melanoma, squamous cell carcinoma, and schwannoma were obtained with minimal morbidity with image guidance. More extensive external approaches were avoided, and appropriate treatment was started without delay. The utility of the image guided approach will be discussed along with the varied pathologies encountered in the pterygopalatine fossa. CONCLUSIONS: 1). One must recognize the diverse, yet related, symptoms of patients presenting with pterygopalatine fossa lesions. Early recognition as well as skull-base imaging is crucial. 2). Biopsy, in addition to imaging, is necessary for diagnosis and may be achieved with little morbidity and increased accuracy using the image guided surgery middle meatus antrostomy approach to the pterygopalatine fossa. 3). The origin of lesions that involve the pterygopalatine fossa may be difficult to identify. Involvement of the pterygopalatine fossa by malignancy may be by contiguous spread, by way of metastasis, or by perineural invasion.