Continuation of telemedicine in otolaryngology post-COVID-19: Applications by subspecialty.

OBJECTIVE: The purpose of this paper is to review the literature and compile key clinically relevant applications of telemedicine for use in otolaryngology relevant to the post-COVID-19 era. STUDY DESIGN: Systematic Literature Review. DATA SOURCES: Pubmed and Google Scholar. REVIEW METHODS: Pubmed and Google Scholar were queried using combined key words such as "telemedicine," "covid" and "otolaryngology." The searches were completed in March-August 2020. Additional queries were made with particular subspecialty phrases such as "rhinology" or "otology" to maximize yield of relevant titles. Relevant articles were selected for abstract review. Applicable abstracts were then selected for review of the full text. RESULTS: Initial search identified 279 results. These were screened for relevance and 100 abstracts were selected for review. Abstracts were excluded if they were not in English, not related to otolaryngology, or if the full text was unavailable for access. Of these, 37 articles were selected for complete review of the full text. CONCLUSION: The sudden healthcare closures during the COVID-19 pandemic resulted in a sharp increase in the use of telemedicine, particularly in subspecialty fields. Otolaryngologists are at a unique risk of infection resulting from the examination of the head and neck and aerosol-generating procedures due to the predilection of viral particles for the nasal cavities and pharynx. The COVID-19 pandemic may have served as a catalyst to implement telemedicine into clinical practice, however identifying ways to integrate telemedicine long term is key for a sustainable and viable practice in the post-COVID-19 era. Although many states are now finding themselves on the down-sloping side of their infection rate curve, many others remain at the apex. Additionally, the risk of future waves of this pandemic, or the onset of another pandemic, should not be overlooked. Practice modification guidelines that mitigate infection risk by utilizing telemedicine would be useful in these instances. Telemedicine can help to reduce infection spread by limiting unnecessary in-person interactions and help conserve personal protective equipment (PPE) by facilitating remote care with the added benefits of expanding care to broad geographic areas, limiting cost, time, and travel burden on patients and families, and enabling consistent follow up.

Comparison of In Vitro Inactivation of SARS CoV-2 with Hydrogen Peroxide and Povidone-Iodine Oral Antiseptic Rinses.

PURPOSE: To evaluate the in vitro inactivation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with hydrogen peroxide (H2 O2 ) and povidone-iodine (PVP-I) oral antiseptic rinses at clinically recommended concentrations and contact times. MATERIALS AND METHODS: SARS-CoV-2, USA-WA1/2020 strain virus stock was prepared prior to testing by growing in Vero 76 cells. The culture media for prepared virus stock was minimum essential medium (MEM) with 2% fetal bovine serum (FBS) and 50 µg/mL gentamicin. Test compounds consisting of PVP-I oral rinse solutions and H2 O2 aqueous solutions were mixed directly with the virus solution so that the final concentration was 50% of the test compound and 50% of the virus solution. Thus PVP-I was tested at concentrations of 0.5%, 1.25%, and 1.5%, and H2 O2 was tested at 3% and 1.5% concentrations to represent clinically recommended concentrations. Ethanol and water were evaluated in parallel as standard positive and negative controls. All samples were tested at contact periods of 15 seconds and 30 seconds. Surviving virus from each sample was then quantified by standard end-point dilution assay and the log reduction value of each compound compared to the negative control was calculated. RESULTS: After the 15-second and 30-second contact times, PVP-I oral antiseptic rinse at all 3 concentrations of 0.5%, 1.25%, and 1.5% completely inactivated SARS-CoV-2. The H2 O2 solutions at concentrations of 1.5% and 3.0% showed minimal viricidal activity after 15 seconds and 30 seconds of contact time. CONCLUSIONS: SARS-CoV-2 virus was completely inactivated by PVP-I oral antiseptic rinse in vitro, at the lowest concentration of 0.5 % and at the lowest contact time of 15 seconds. Hydrogen peroxide at the recommended oral rinse concentrations of 1.5% and 3.0% was minimally effective as a viricidal agent after contact times as long as 30 seconds. Therefore, preprocedural rinsing with diluted PVP-I in the range of 0.5% to 1.5% may be preferred over hydrogen peroxide during the COVID-19 pandemic.

Rapid In-Vitro Inactivation of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Using Povidone-Iodine Oral Antiseptic Rinse.

PURPOSE: To investigate the optimal contact time and concentration for viricidal activity of oral preparation of povidone-iodine (PVP-I) against SARS-CoV-2 ('corona virus') to mitigate the risk and transmission of the virus in the dental practice. MATERIALS AND METHODS: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) USA-WA1/2020 strain, virus stock was tested against oral antiseptic solutions consisting of aqueous povidone-iodine (PVP-I) as the sole active ingredient. The PVP-I was tested at diluted concentrations of 0.5%, 1%, and 1.5%. Test media without any virus was added to 2 tubes of the compounds to serve as toxicity and neutralization controls. Ethanol (70%) was tested in parallel as a positive control, and water only as a negative control. The test solutions and virus were incubated at room temperature (22 ± 2 °C) for time periods of 15 and 30 seconds. The solution was then neutralized by a 1/10 dilution in minimum essential medium (MEM) 2% fetal bovine serum (FBS), 50 µg/mL gentamicin. Surviving virus from each sample was quantified by standard end-point dilution assay and the log reduction value (LRV) of each compound compared to the negative (water) control was calculated. RESULTS: PVP-I oral antiseptics at all tested concentrations of 0.5%, 1%, and 1.5%, completely inactivated SARS-CoV-2 within 15 seconds of contact. The 70% ethanol control group was unable to completely inactivate SARS-CoV-2 after 15 seconds of contact, but was able to inactivate the virus at 30 seconds of contact. CONCLUSIONS: PVP-I oral antiseptic preparations rapidly inactivated SARS-CoV-2 virus in vitro. The viricidal activity was present at the lowest concentration of 0.5 % PVP-I and at the lowest contact time of 15 seconds. This important finding can justify the use of preprocedural oral rinsing with PVP-I (for patients and health care providers) may be useful as an adjunct to personal protective equipment, for dental and surgical specialties during the COVID-19 pandemic.

Rhinologist Use of Antibiotics With Nasal Packing for Epistaxis.

BACKGROUND: There is limited evidence supporting the usage of prophylactic antibiotics in the setting of nasal packing for epistaxis. It is unclear what current antiobiotic usage patterns are by otolaryngologists. OBJECTIVES: Characterize the antibiotic prescribing practices employed by otolaryngologists in the management of epistaxis patients treated with packing as well as the underlying rationale. Explore the impact of experience, geography, and academic affiliation on treatment decisions. METHODS: An anonymous survey of antibiotic prescribing patterns for patients with epistaxis requiring nasal packing was distributed to all physician members of the American Rhinologic Society. Responses to each question were descriptively summarized including 95% confidence intervals and were linked to demographics using Fisher's exact tests. RESULTS: One thousand one hundred and thirteen surveys were distributed with 307 responses (27.6%). Antibiotic prescription rates varied based on packing type, with 20.0% prescribing antibiotics for dissolvable packing compared to 84.2% to 84.6% for nondissolvable packing. The absorbance of nondissolvable packing does not impact the decision to prescribe antibiotics (P > .999). Precisely 69.7% (95% CI: 64.0%-74.8%) stop antibiotics immediately following packing removal. Precisely 85.6% (95% CI: 81.6%-89.9%) cite the risk of toxic shock syndrome (TSS) when prescribing antibiotics. Notable regional differences include greater utilization of amoxicillin-clavulanate in the Midwest (67.6%) and Northeast (61.4%) as compared with the South (42.1%) and West (45.1%) (P = .013). Further, years in practice were positively associated with several patterns including prescribing antibiotics for patients with dissolvable packing (P = .008), citing prevention of sinusitis as a rationale for antibiotic use (P < .001), and a higher likelihood of having treated a patient with TSS (P = .002). CONCLUSIONS: Antibiotic use in patients with epistaxis controlled with nondissolvable packing is common. Treatment patterns are influenced by geography, years in practice, and practice type. LEVEL OF EVIDENCE: 4.

Allergies and Natural Alternatives.

Complementary and integrative medicine therapies in the treatment of allergy and allergic rhinitis (AR) are divided broadly into the categories of nutritional supplements, herbal supplements, Ayurvedic, and Chinese traditional medicine. Some therapies are likely completely safe, such as Manuka honey, with no known side effects. Others have significant risks, such as ephedra, which was ultimately banned for use by the Food and Drug Administration. The efficacy of these therapies is varied and under-researched. The therapies with the strongest evidence in the treatment of allergy and AR are Manuka honey, butterbur, and Sinupret.

Efficacy of Povidone-Iodine Nasal and Oral Antiseptic Preparations Against Severe Acute Respiratory Syndrome-Coronavirus 2 (SARS-CoV-2).

INTRODUCTION: Severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) is the pathogen responsible for the global pandemic of coronavirus disease 2019 (COVID-19). From the first reported cases in December 2019, the virus has spread to over 4 million people worldwide. Human-to-human transmission occurs mainly through the aerosolization of respiratory droplets. Transmission also occurs through contact with contaminated surfaces and other fomites. Improved antisepsis of human and nonhuman surfaces has been identified as a key feature of transmission reduction. There are no previous studies of povidone iodine (PVP-I) against SARS-CoV-2. This study evaluated nasal and oral antiseptic formulations of PVP-I for virucidal activity against SARS-CoV-2. This is the first report on the efficacy of PVP-I against the virus that causes COVID-19. METHODS: Povidone iodine nasal antiseptic formulations and PVP-I oral rinse antiseptic formulations from 1% to 5% concentrations as well as controls were studied for virucidal efficacy against the SARS-CoV-2. Test compounds were evaluated for ability to inactivate SARS-CoV-2 as measured in a virucidal assay. SARS-CoV-2 was exposed directly to the test compound for 60 seconds, compounds were then neutralized, and surviving virus was quantified. RESULTS: All concentrations of nasal antiseptics and oral rinse antiseptics evaluated completely inactivated the SARS-CoV-2. CONCLUSIONS: Nasal and oral PVP-I antiseptic solutions are effective at inactivating the SARS-CoV-2 at a variety of concentrations after 60-second exposure times. The formulations tested may help to reduce the transmission of SARS-CoV-2 if used for nasal decontamination, oral decontamination, or surface decontamination in known or suspected cases of COVID-19.

Povidone-Iodine Use in Sinonasal and Oral Cavities: A Review of Safety in the COVID-19 Era.

OBJECTIVES: Approaches to nasal and oral decontamination with povidone-iodine (PVP-I) have been published to reduce nosocomial spread of Severe Acute Respiratory Syndrome-Coronavirus 2 (SARS-CoV-2). The safety of PVP-I topically applied to the nasal and oral cavity is addressed by a literature review. The specific efficacy of PVP-I against coronaviruses and its potential efficacy against SARS-CoV-2 is discussed. METHODS: A review was performed utilizing PubMed and Cochrane Databases. All citations in protocols for nasal and oral PVP-I use regarding COVID-19 were independently reviewed. RESULTS: Povidone-iodine has been safely administered for up to 5 months in the nasal cavity and 6 months in the oral cavity. Concentrations less than 2.5% in vitro do not reduce ciliary beat frequency or cause pathological changes in ciliated nasal epithelium, upper respiratory, or mucosal cells. Adverse events with oral use have not been reported in conscious adults or children. Allergy and contact sensitivity is rare. Chronic mucosal use up to 5% has not been shown to result in clinical thyroid disease. PVP-I is rapidly virucidal and inactivates coronaviruses, including SARS-CoV and Middle East Respiratory Syndrome (MERS). CONCLUSIONS: Povidone-iodine can safely be used in the nose at concentrations up to 1.25% and in the mouth at concentrations up to 2.5% for up to 5 months. Povidone-iodine rapidly inactivates coronaviruses, including SARS and MERS, when applied for as little as 15 seconds. There is optimism that PVP-I can inactivate SARS-CoV-2, but in vitro efficacy has not yet been demonstrated.

In Vitro Efficacy of a Povidone-Iodine Nasal Antiseptic for Rapid Inactivation of SARS-CoV-2.

Importance: Research is needed to demonstrate the efficacy of nasal povidone-iodine (PVP-I) against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Objective: To evaluate the in vitro efficacy of PVP-I nasal antiseptic for the inactivation of SARS-CoV-2 at clinically significant contact times of 15 and 30 seconds. Interventions: The SARS-CoV-2, USA-WA1/2020 strain, virus stock was tested against nasal antiseptic solutions consisting of aqueous PVP-I as the sole active ingredient. Povidone-iodine was tested at diluted concentrations of 0.5%, 1.25%, and 2.5% and compared with controls. The test solutions and virus were incubated at mean (SD) room temperature of 22 (2) °C for time periods of 15 and 30 seconds. Design and Setting: This controlled in vitro laboratory research study used 3 different concentrations of study solution and ethanol, 70%, as a positive control on test media infected with SARS-CoV-2. Test media without virus were added to 2 tubes of the compounds to serve as toxicity and neutralization controls. Ethanol, 70%, was tested in parallel as a positive control and water only as a negative control. Main Outcomes and Measures: The primary study outcome measurement was the log reduction value after 15 seconds and 30 seconds of given treatment. Surviving virus from each sample was quantified by standard end point dilution assay, and the log reduction value of each compound was compared with the negative (water) control. Results: Povidone-iodine nasal antiseptics at concentrations (0.5%, 1.25%, and 2.5%) completely inactivated SARS-CoV-2 within 15 seconds of contact as measured by log reduction value of greater than 3 log10 of the 50% cell culture infectious dose of the virus. The ethanol, 70%, positive control did not completely inactivate SARS-CoV-2 after 15 seconds of contact. The nasal antiseptics tested performed better than the standard positive control routinely used for in vitro assessment of anti-SARS-CoV-2 agents at a contact time of 15 seconds. No cytotoxic effects on cells were observed after contact with each of the nasal antiseptics tested. Conclusions and Relevance: Povidone-iodine nasal antiseptic solutions at concentrations as low as 0.5% rapidly inactivate SARS-CoV-2 at contact times as short as 15 seconds. Intranasal use of PVP-I has demonstrated safety at concentrations of 1.25% and below and may play an adjunctive role in mitigating viral transmission beyond personal protective equipment.

Endoscopic pituitary surgery: a systematic review and meta-analysis.

OBJECT: Surgery on the pituitary gland is increasingly being performed through an endoscopic approach. However, there is little published data on its safety and relative advantages over traditional microscope-based approaches. Published reports are limited by small sample size and nonrandomized study design. A meta-analysis allows for a description of the impact of endoscopic surgery on short-term outcomes. METHODS: The authors performed retrospective review of data from their institution as well as a systematic review of the literature. The pooled data were analyzed for descriptive statistics on short-term outcomes. RESULTS: Nine studies (821 patients) met inclusion criteria. Overall, the pooled rate of gross tumor removal was 78% (95% CI 67-89%). Hormone resolution was achieved in 81% (95% CI 71-91%) of adrenocorticotropic hormone secreting tumors, 84% (95% CI 76-92%) of growth hormone secreting tumors, and 82% (95% CI 70-94%) of prolactin secreting tumors. The pooled complication rates were 2% (95% CI 0-4%) for CSF leak and 1% (95% CI 0-2%) for permanent diabetes insipidus. There were 2 deaths reported in the literature that were both related to vascular injury, giving an overall mortality rate of 0.24%. CONCLUSIONS: The results of this meta-analysis support the safety and short-term efficacy of endoscopic pituitary surgery. Future studies with long-term follow-up are required to determine tumor control.

Nasal Endoscopy Billing Patterns: A Survey of the American Rhinologic Society.

Introduction Nasal endoscopy (NE) is an essential element of office-based clinical rhinology, including the evaluation of chronic rhinosinusitis. Despite the presence of guidelines, variability exists regarding coding and billing for NE especially with regard to inclusion of evaluation and management (E&M) codes and use of the 25 modifier. The goal of this survey was to assess the billing patterns for NE among American Rhinologic Society (ARS) members. Methods An invitation to participate in a web-based survey was electronically sent to all ARS members. Survey participants were queried regarding demographics and billing patterns for NE in several different clinical scenarios using a 5-point Likert-type scale, with a score of 5 representing "always" and a score of 1 representing "never" for billing E&M. Results A total of 93 respondents successfully completed the survey with a range of the number of years since completing training, practice type (50.5% private, 44.1% academic) and completion of a rhinology fellowship (40.9%). Variable responses for billing patterns for distinct clinical scenarios were noted. Higher scores for billing both E&M and NE for the queried clinical scenarios were noted for new patients (mean 4.50) compared to established patients (mean 3.81) and postoperative patients (mean 3.04). Inclusion of a septoplasty as part of the surgery impacted billing an E&M code 28% of the time. Practice type and history of performing a fellowship did not significantly influence billing patterns for NE. Conclusions Significant variability exists among ARS respondents with regard to billing patterns for NE, despite the presence of coding guidelines. Additional teaching of standard coding practices for NE may limit variability among otolaryngologists.

Role of perioperative antibiotics in endoscopic skull base surgery.

OBJECTIVES/HYPOTHESIS: Direct connection between the sinonasal and intracranial cavities and passage of multiple instruments and graft materials through a contaminated field occur routinely during endoscopic pituitary and skull base surgery. Despite the theoretical risk of intracranial contamination with sinonasal flora, the incidence of central nervous system (CNS) infection following such procedures is not well documented, and the ideal antibiotic regimen has yet to be determined. STUDY DESIGN: Prospective case series of 24 to 48 hours of single-agent perioperative antibiotics in patients undergoing endoscopic skull base surgery. METHODS: Prospective database of procedures performed between January 2004 and May 2006 was reviewed for antibiotic use and infectious complications. RESULTS: The diagnoses of the 90 patients in this series included pituitary tumor (62%), craniopharyngioma (9%), encephalocele (9%), and meningioma (8%). Fifty-eight (64%) patients experienced intraoperative cerebrospinal fluid (CSF) leak. A variety of autologous, synthetic grafts, hemostatic agents, and tissue sealants were placed through the sinonasal cavity for reconstruction. All patients received 24 to 48 hours of a single antibiotic based on patient sensitivity: cefazolin (87%), vancomycin (10%), or clindamycin (3%). Additional antibiotics were subsequently required during the hospital stay in eight (9%) patients for a variety of indications. There were no cases of intracranial infections or meningitis in patients with or without intraoperative CSF leak. CONCLUSIONS: Despite direct contamination of the intracranial cavity during endoscopic, endonasal skull base surgery, the risk of CNS infections is low. Limited use of a single perioperative antibiotic may be sufficient prophylaxis.

Algorithm for reconstruction after endoscopic pituitary and skull base surgery.

INTRODUCTION: The expanding role of endoscopic skull base surgery necessitates a thorough understanding of the indications, techniques, and limitations of the various approaches to reconstruction. The technique and outcomes of endoscopic skull base reconstruction remain incompletely described in the literature. STUDY DESIGN AND METHODS: Patients undergoing endoscopic skull base surgery underwent an algorithmic approach to reconstruction based on tumor location, defect size, and presence of intraoperative cerebrospinal fluid (CSF) leak. A prospective database was reviewed to determine the overall efficacy of reconstruction and to identify risk factors for postoperative CSF leak. RESULTS: The diagnosis in the 127 patients in this series included pituitary tumor in 70 (55%) patients, encephalocele in 16 (12.6%) patients, meningioma in 11 (8.7%) patients, craniopharyngioma in 9 (7.1%) patients, and chordoma in 6 (4.7%) patients. Successful reconstruction was initially achieved in 91.3% of patients. Eleven (8.7%) patients experienced postoperative CSF leak, 10 of which resolved with lumbar drainage alone. One (0.8%) patient required revision surgery. Correlation between postoperative CSF leak and study variables revealed a statistically significant longer duration of surgery (243 vs. 178 min, P = .008) and hospitalization (12.1 vs. 4.5 days, P < .0001) and a trend toward larger tumors (mean, 3.2 vs. 2.3 cm; P = .058) in patients experiencing postoperative CSF leak. CONCLUSION: The algorithm for reconstruction after endoscopic surgery presented in this study is associated with excellent overall efficacy. A greater understanding of risk factors for postoperative CSF leak is imperative to achieve optimal results.

Mitomycin C and endoscopic sinus surgery: where are we?

PURPOSE OF REVIEW: Mitomycin C has been used successfully in various ophthalmologic and, more recently, otolaryngologic procedures. Its modulation of fibroblast activity allows for decreased scarring and fibrosis. Several recent trials have examined the efficacy of mitomycin C in reducing synechia and stenosis following endoscopic sinus surgery. RECENT FINDINGS: Basic science studies using fibroblast cell lines have demonstrated a dose-dependent suppression of activity with the use of mitomycin C. This is further supported by animal studies that have shown lower rates of maxillary ostial restenosis following application of mitomycin C. No human trial, however, has demonstrated a statistically significant impact of mitomycin C on the incidence of postoperative synechia or stenosis following sinus surgery. The limitations of the literature are discussed. SUMMARY: The antiproliferative properties of mitomycin C may theoretically decrease the incidence of synechia and stenosis following endoscopic sinus surgery. Although this is supported by basic science studies and its successful use in other fields, the clinical evidence to date has not shown the application of mitomycin C to be effective in preventing stenosis after endoscopic sinus surgery. Future prospective studies are required before definitive conclusions can be made.

Feasibility of near real-time image-guided sinus surgery using intraoperative fluoroscopic computed axial tomography.

OBJECTIVE: One of the main limitations of image-guided surgery is that navigation relies on the use of a CT scan obtained before surgery and is unable to be updated during the procedure. A software addition has been developed to allow reconstruction of CT-like images from a series of fluoroscopic scans and integrate these into an image-guided system (GE Healthcare Surgical Navigation, Lawrence, MA). We report our initial experience with a series of patients undergoing intraoperative fluoroscopic navigation in sinus surgery. STUDY DESIGN AND SETTINGS: After institutional review board clearance, we prospectively studied 14 consecutive patients undergoing image-guided sinus surgery with the use of intraoperative fluoroscopy. RESULTS: All patients had preoperative and postoperative fluoroscopic images reconstructed into CT-like images. By the conclusion of the study, images were adequate in quality and accurate navigation was achieved. CONCLUSION: Real-time image-guided sinus surgery using fluoroscopy is feasible. Future studies will need to focus on defining the procedures that could benefit, such as tumor resection, to enhance patient safety during these operations.

Lateral thyrotomy for excision of laryngeal paragangliomas.

Laryngeal paragangliomas, although rare, are lesions that warrant appropriate diagnosis and treatment secondary to their location and high risk of bleeding when violated. This article describes a method to workup patients with solid submucosal lesions of the larynx to diagnose a paraganglioma without a biopsy. When recognized preoperatively, a lateral approach to removal can be performed, decreasing the risk of significant bleeding and the need for tracheotomy or permanent laryngostoma. This article also adds two more cases to the reported literature of 75.

Validation of a new grading system for endoscopic examination of adenoid hypertrophy.

OBJECTIVE: To propose and validate a new subjective grading system of adenoid size with flexible fiberoptic evaluation. STUDY DESIGN AND SETTING: Digital video clips of 24 flexible fiberoptic nasopharyngeal exams were presented to 24 examiners (otolaryngology resident and consultant physicians) at a tertiary care institution. Examiners were asked to use the proposed grading system to rate adenoid hypertrophy. Kappa statistical analysis was used to evaluate the degree of intergrader agreement or disagreement. RESULTS: Statistical analysis of intergrader agreement demonstrated an overall Kappa score of 0.71 suggesting a "substantial" strength of agreement. The Kappa strength of agreement was found to be 0.83 (almost perfect) among consultant physicians and 0.62 (substantial) among resident physicians. CONCLUSIONS: The proposed adenoid staging system is a reliable and consistent method of staging adenoid tissue size. SIGNIFICANCE: This new validated grading system may be a useful standard for reporting adenoid size in future clinical outcome studies.

Early extubation following major tracheal surgery in select children.

Major airway surgery in children has traditionally consisted of a period of endotracheal intubation after the procedure for a period of 1-2 weeks to ensure stability of the repair. Recent literature has supported a trend toward decreasing this time period to prevent the consequences of leaving a foreign body in the airway and the morbidity associated with the use of sedation and narcotics in children. We present a series of five select children from our institution that underwent major tracheal surgery and were successfully extubated early in their postoperative course; four on postoperative day number 1. This demonstrates the feasibility of this approach in select patients.

Medical Management of Frontal Sinusitis.

Rhinosinusitis is a term that has long been used to describe a diverse disease entity that encompasses several related but distinct conditions involving the paranasal sinuses. Frontal sinusitis represents one such entity with its own unique treatment considerations. Like rhinosinusitis as a whole, the role of medical management in the treatment of frontal sinusitis cannot be overlooked. Contemporary medical management of frontal sinusitis requires recognition of the unique disease process with implementation of targeted therapies aimed at addressing the specific pathophysiology.

Neck recurrence and mortality in esthesioneuroblastoma: Implications for management of the N0 neck.

OBJECTIVES/HYPOTHESIS: To review the literature on neck recurrence in esthesioneuroblastoma. STUDY DESIGN: PubMed database. METHODS: A PubMed database search was performed using keywords "esthesioneuroblastoma," "olfactory neuroblastoma," and "esthesioneuroblastoma neck metastasis." Articles written in English with greater than 10 subjects that had data regarding the association of neck recurrence and mortality and/or the association of neck recurrence with Kadish stage were included for analysis. RESULTS: Thirteen studies met inclusion criteria with information regarding the association of neck recurrence and mortality, and 15 studies had data associating neck recurrence and Kadish stage. The neck recurrence rate was 14.1% in studies analyzing mortality. Among those patients who developed regional metastases, mortality was 60%. Of patients without regional recurrence, the mortality rate from disease was 26% (P < 0.0001) and overall mortality was 32% (P < 0.0001). The rate of neck recurrence within each Kadish stage was 0%, 11%, 21%, and 18% for Kadish stages A, B, C, and D, respectively. The trend toward an increased incidence of neck recurrence from stage A to stage D is statistically significant, with P value 0.003. CONCLUSION: The rate of neck recurrence in esthesioneuroblastoma is close to 15%. There is a strong association of recurrence with Kadish stage B and C. Mortality from disease in patients with recurrence in cervical lymph nodes is significant when compared to those who never develop neck disease. Prospective studies are needed to evaluate a potential role for elective neck dissection versus elective neck radiation for patients with esthesioneuroblastoma. LEVEL OF EVIDENCE: N/A. Laryngoscope, 126:1373-1379, 2016.

Chronic rhinosinusitis osteoblasts differ in cellular properties from normal bone.

BACKGROUND: Osteitis, characterized by bony thickening and remodeling, is often considered a hallmark of recalcitrant rhinosinusitis. However, there is limited literature examining the bone in chronic rhinosinusitis (CRS) pathology. In this study we cultured osteoblasts from bone harvested during sinus surgery as well as from nondiseased controls to compare their cellular properties. METHODS: Sinus bone was collected during sinus and skull-base surgery and placed in proliferation media. Outgrowth of cells occurred at 2 weeks and the cells were confirmed to be osteoblasts by alkaline phosphatase staining. Cellular adhesion was determined by replating and counting adhered cells at 4 hours. Proliferation of cells plated for 24 hours was assayed by measuring [(3) H]-thymidine incorporation. Calcium content was measured by changing cells to differentiation media and measuring the calcium content on days 7, 14, and 21. RESULTS: Alkaline phosphatase assay showed more than 90% of osteoblasts staining in all samples. Osteoblasts from patients with CRS had significant decreases in adhesion (p < 0.01) compared to osteoblasts from skull-base patients. There was a significant (p < 0.05) increase in calcium content in rhinosinusitis samples compared with the nondiseased sinus bone samples. CONCLUSION: To date, this is the first known study that shows a direct comparison of osteoblast properties between patients with and without CRS. Our results indicate that there are fundamental phenotypic differences in adhesion and mineralization between osteoblasts in patients with CRS compared to controls.