A Game Theory Approach for Strategic Partnerships in Academic Medicine.

Forming strategic partnerships is vital to academic health centers to further their missions of patient care, education, research, and community engagement. Formulating a strategy for such partnerships can be daunting due to the complexities of the health care landscape. The authors propose a game theory approach to partnership formation with the players being gatekeepers, facilitators, organizational employees, and economic buyers. Forming an academic partnership is not a game that is typically won or lost but is rather an ongoing engagement. Consistent with our game theory approach, the authors propose six basic rules to assist in successful strategic partnership formation for academic health centers.

Order Substitutions and Education for Balanced Crystalloid Solution Use in an Integrated Health Care System and Association With Major Adverse Kidney Events.

Importance: Trials comparing balanced crystalloids with normal saline have yielded mixed results regarding reductions in kidney complications and mortality for hospitalized patients receiving intravenous fluids. Objective: To evaluate the association of a multifaceted implementation program encouraging the preferential use of lactated Ringer solution with patient outcomes and intravenous fluid-prescribing practices in a large, multilevel health care system. Design, Setting, and Participants: This type 2 hybrid implementation and comparative effectiveness study enrolled all patients 18 years or older who received 1 L or more of intravenous fluids while admitted to an emergency department and/or inpatient unit at 1 of 22 hospitals in Idaho and Utah between November 1, 2018, and February 29, 2020. An interrupted time series analysis was used to assess study outcomes before and after interventions to encourage use of lactated Ringer solution. Exposures: Implementation program combining order set modification, electronic order entry alerts, and sequential clinician-targeted education to encourage prescribing of lactated Ringer solution instead of normal saline. Main Outcomes and Measures: The primary implementation outcome was the patient-level proportion of intravenous fluids that was balanced crystalloids. The primary effectiveness outcome was the incidence of major adverse kidney events (MAKE30)-a composite of new persistent kidney dysfunction, new initiation of dialysis, and death-at 30 days. Results: Among 148 423 patients (median [IQR] age, 47 [30-67] years; 91 302 women [61%]), the proportion of total fluids received that was lactated Ringer solution increased from 28% to 75% in the first week vs the last week of the study (immediate implementation effect odds ratio [OR], 3.44; 95% CI, 2.79-4.24). The estimated MAKE30 absolute risk reduction was 2.2% (95% CI, 1.3%-3.3%) based on interrupted time series analysis showing a decrease in the week-on-week trend for MAKE30 (OR difference, 0.03; 95% CI, 0.03-0.03, P < .001). The immediate postimplementation OR for MAKE30 was 0.88 (95% CI, 0.76-1.01), with a decrease in persistent kidney dysfunction (OR, 0.80; 95% CI, 0.69-0.93) and mortality (OR, 0.78; 95% CI, 0.65-0.93) but not dialysis (OR, 1.00; 95% CI, 0.76-1.32). Conclusions and Relevance: In this comparative effectiveness study, an implementation program was associated with an increase in the proportion of fluids administered as lactated Ringer solution compared with normal saline and was associated with a reduction in MAKE30 events among patients treated in a large integrated health care system.

Deductible Status in the Pediatric Population: A Barrier to Appropriate Care?

OBJECTIVE: The objective of this study is to evaluate the impact of high-deductible health plans on elective surgery (tonsillectomy) in the pediatric population. STUDY DESIGN: Cross-sectional study. SETTING: Health claims database from a third-party payer. METHODS: Data were reviewed for children up to 18 years of age who underwent tonsillectomy or arm fracture repair (nonelective control) from 2016 to 2019. Incidence of surgery by health plan deductible (high, low, or government insured) and met or unmet status of deductibles were compared. RESULTS: A total of 10,047 tonsillectomy claims and 9903 arm fracture repair claims met inclusion and exclusion criteria. The incidence of tonsillectomy was significantly different across deductible plan types. Patients with met deductibles were more likely to undergo tonsillectomy. In patients with deductibles ≥$4000, a 1.75-fold increase in tonsillectomy was observed in those who had met their deductible as compared with those who had not. These findings were not observed in controls (nonelective arm fracture). For those with met deductibles, those with high deductibles were much more likely to undergo tonsillectomy than those with low, moderate, and government deductibles. Unmet high deductibles were least likely to undergo tonsillectomy. CONCLUSIONS: Health insurance plan type influences the incidence of pediatric elective surgery such as tonsillectomy but not procedures such as nonelective repair of arm fracture. High deductibles may discourage elective surgery for those deductibles that are unmet, risking inappropriate care of vulnerable pediatric patients. However, meeting the deductible may increase incidence, raising the question of overutilization.

Are Opioids Necessary in Middle Ear Surgery? Comparing the Transcanal and Postauricular Approach.

OBJECTIVE: Understand opioid-prescribing patterns in otologic surgery and the difference in opioid use between transcanal and postauricular surgery. STUDY DESIGN: Prospective survey. SETTING: Multihospital network. PATIENTS: All patients undergoing otologic surgery from March 2017 to January 2019. INTERVENTION: Patients undergoing otologic surgery were surveyed regarding postoperative opioid use and their level of pain control. Patients were divided by surgical approach (transcanal vs. postauricular). Those who underwent mastoid drilling were excluded. Narcotic amounts were converted to milligram morphine equivalents (MME) for analysis. MAIN OUTCOME MEASURES: Amount of opioid was calculated and compared between the two groups. Mann-Whitney U test and Chi-square testing were used for analysis. RESULTS: Fifty-five patients were included in the analysis; of these 18 (33%) had a postauricular incision. There was no difference in age (p = 0.85) or gender (p = 0.5) between the two groups. The mean amount of opioid prescribed (MME) in the postauricular and transcanal groups was 206.4 and 143 (p = 0.038) while the mean amount used was 37.7 and 37.5 (p = 0.29) respectively. There was no difference in percentage of opioid used (p = 0.44) or in patient-reported level of pain control (p = 0.49) between the two groups. CONCLUSION: Patients in both the transcanal and postauricular groups used only a small portion of their prescribed opioid. There was no difference in the amount of opioid used or the patient's reported level of pain control based on the approach. Otologic surgeons should be aware of these factors to reduce narcotic diversion after ear surgery.

Multi-institutional Evaluation of Radiologic Findings Associated With Pediatric Congenital Idiopathic Bilateral Vocal Fold Dysfunction.

OBJECTIVE: To report brain magnetic resonance imaging (MRI) and ultrasonography findings in pediatric patients with congenital idiopathic bilateral vocal fold dysfunction and analyze factors associated with its etiology and resolution. STUDY DESIGN: Case series with retrospective review. SETTING: Tertiary care multi-institutional setting: Nationwide Children's Hospital, Indiana University, University of North Carolina, and Cleveland Clinic. METHODS: Pediatric patients with congenital idiopathic bilateral vocal fold dysfunction were included in this review. RESULTS: Congenital idiopathic bilateral vocal fold dysfunction was identified in 74 patients from 2000 to 2018. Brain MRI scans were performed in all patients and ultrasonography in 30 (40.5%). Normal imaging results were most commonly found in patients born full-term (P < .0001) or via vaginal delivery (P < .01). Abnormal brain MRI and ultrasound results were found in 38 of 74 (51.3%) and 16 of 30 (53.3%), respectively. Type I Chiari malformation was not identified in any patient. No specific brain MRI or ultrasound abnormality was associated with patients' bilateral vocal fold dysfunction. Complete/incomplete bilateral vocal fold resolution occurred in 45 of 74 (60.8%) patients over the study interval and was not associated with brain MRI or ultrasound findings or birth complications but was associated with vaginal delivery (P = .02). Resolution rates were highest for patients with bilateral vocal fold paramedian paralysis (P = .05). CONCLUSIONS: In this multi-institutional study, no specific brain MRI or ultrasound abnormality was associated with patients' bilateral vocal fold dysfunction or subsequent resolution rates. While imaging is often performed to detect and treat any reversible causes of bilateral vocal fold dysfunction, in this series, imaging findings were heterogeneous and did not identify any treatable causes, such as type I Chiari malformation.

What Is the Impact of Prior Authorization on the Incidence of Pediatric Tonsillectomy?

OBJECTIVE: Third-party payers advocate for prior authorization (PA) to reduce overutilization of health care resources. The impact of PA in elective surgery is understudied, especially in cases where evidence-based clinical practice guidelines define operative candidacy. The objective of this study is to investigate the impact of PA on the incidence of pediatric tonsillectomy. STUDY DESIGN: Cross-sectional study. SETTING: Health claims database from a third-party payer. METHODS: Any pediatric patient who had evaluation for tonsillectomy from 2016 to 2019 was eligible for inclusion. A time series analysis was used to evaluate the change in incidence of tonsillectomy before and after PA. Lag time from consultation to surgery before and after PA was compared with segmented regression. RESULTS: A total of 10,047 tonsillectomy claims met inclusion and exclusion criteria. Female patients made up 51% of claims, and the mean age was 7.9 years. Just 1.5% of claims were denied after PA implementation. There was no change in the incidence of tonsillectomy for all plan types (P = .1). Increased lag time from consultation to surgery was noted immediately after PA implementation by 2.38 days (95% CI, 0.23-4.54; P = .030); otherwise, there was no significant change over time (P = .98). CONCLUSION: A modest number of tonsillectomy claims were denied approval after implementation of PA. The value of PA for pediatric tonsillectomy is questionable, as it did not result in decreased incidence of tonsillectomy in this cohort.

Opioid Prescribing and Use in Ambulatory Otolaryngology.

OBJECTIVES: The objective of this study was to evaluate surgeon-prescribing patterns and opioid use for patients undergoing common otolaryngology surgeries. We hypothesized that there was little consistency across surgeons in prescribing patterns and that surgeons prescribed significantly more opioids than consumed by patients. METHODS: E-mail-based surveys were sent to all postoperative patients across a 23-hospital system. The survey assessed quantity of opioids consumed postoperatively, patient-reported pain control, and methods of opioid disposal. We compared patient-reported opioid consumption to opioids prescribed based on data in the electronic data warehouse. RESULTS: There was wide variation in prescribing between providers both in the quantity and type of opioids prescribed. Patients used significantly less opioids than they were prescribed (10 vs. 30 tablets, P < 0.001) for both opioid-exposed and opioid-naïve patients. More than 75% of patients had excess opioids remaining. CONCLUSION: Opioids are consistently overprescribed following ambulatory head and neck surgery. Otolaryngologists have an important role in the setting of the national opioid epidemic and should be involved in efforts to reduce excess opioids in their community. LEVEL OF EVIDENCE: 4 Laryngoscope, 130: 1913-1921, 2020.

Preoperative ultrasound for the diagnosis of thyroglossal duct cysts: A validation study.

OBJECTIVES: To evaluate the use of ultrasound to distinguish between thyroglossal duct cysts (TGDC) and dermoid cysts (DC) for surgical planning. To validate the SIST (septae + irregular wall + solid components = TGDC) scoring system proposed by Oyewumi et al. [1]. METHODS: This was a retrospective chart review of pediatric patients with midline neck masses who presented between the years of 2005 and 2014 and underwent preoperative ultrasound and surgical resection. Two pediatric radiologists blinded to diagnosis reviewed each US for 14 separate characteristics. According to the SIST scoring system, one point was given for each of the following: internal septae, irregular walls, and solid components. RESULTS: 45 patients met inclusion criteria. Final pathologic diagnosis showed 29 patients had TGDC, 16 had DC. The majority of patients with both TGDC and DC earned SIST scores of 0. CONCLUSION: While ultrasound remains a useful part of the work-up of lesions of the head and neck in children, this small retrospective study was not able to validate the previously proposed SIST scoring system None of the parameters discussed in the original paper was found to be a statistically significant determinant of TGDC.

Metastasis of Ewing's sarcoma to the thyroid gland: A case report.

Ewing's sarcoma (ES) is an aggressive pediatric malignancy. We present a case of ES with thyroid metastasis. The patient was diagnosed with ES at age 8. Despite aggressive treatment, she suffered disease progression. Surveillance demonstrated a left thyroid lesion. This grew rapidly within 2 months, causing tracheal compression. She underwent hemi-thyroidectomy to prevent airway compromise. Due to her refractory ES, she was enrolled in the Vigil immunotherapy vaccine trial; thus, the specimen was used for vaccine development. This is the first reported case of skeletal ES with metastasis to the thyroid, requiring hemithyroidectomy to prevent airway compromise.

Surgical management of neck pain and headache associated with pediatric hashimoto's thyroiditis.

OBJECTIVES/HYPOTHESIS: Case reports of a painful variant of Hashimoto's thyroiditis exist in the literature; however, these cases have only been documented in adult patients and there are no standard treatment guidelines. The aim of this study was to describe an alternative management for Hashimoto's thyroiditis associated with medically intractable head and neck pain in the pediatric population. STUDY DESIGN: Case series with chart review. METHODS: The study was conducted in the Section of Pediatric Otolaryngology at the Cleveland Clinic. We retrospectively analyzed pediatric patients (ages 0-18 years) with painful thyroiditis and/or headache who underwent total thyroidectomy from 2005 to 2014 with a clinical diagnosis of Hashimoto's thyroiditis. A thorough chart review was performed, including medical and family history, presenting symptoms, laboratory values, medical and surgical treatment strategies, operative reports, and surgical pathology. RESULTS: There were 0.02% of patients (5 of 305) who met the criteria of intractable head and or neck pain. All five underwent total thyroidectomy with confirmation of Hashimoto's thyroiditis on surgical pathology. Surgical treatment resulted in complete cervical pain relief and improved headaches with a minimum follow-up of 36 months. CONCLUSIONS: Hashimoto's thyroiditis is a relatively common form of autoimmune thyroiditis in pediatric patients that uncommonly results in intractable neck pain or headache. In this case series, thyroidectomy was an effective alternative treatment in the pediatric population for medical failures in chronic painful Hashimoto's thyroiditis. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:2213-2217, 2018.

Association of Enrollment in an Aerodigestive Clinic With Reduced Hospital Stay for Children With Special Health Care Needs.

Importance: Children with special health care needs (CSHCN) have disproportionate health care utilization. Previous studies have demonstrated that a primary medical home improves health care outcomes for this population. Objective: To elucidate if enrollment in a multidisciplinary aerodigestive clinic improves outcomes and reduces health care costs by decreasing admissions and inpatient days. Design, Setting, and Participants: A retrospective medical record review of 113 patients with aerodigestive disorders enrolled in a pediatric multidisciplinary clinic from June 2009 to December 2013 was performed. Of the 113 particpants, 58 (51.3%) were male, 59 (52.2%) had a tracheostomy, and 90 (80.5%) had a gastrostomy tube during their enrollment period. Patient ages at enrollment ranged from 0 to 20 years, with 59 (52.2%) ranging from 0 to 5 years, 23 (20.4%) ranging from 6 to 10 years, 18 (15.9%) ranging from 11 to 15 years, and 13 (11.5%) being 16 years or older. Admissions data before and after enrollment in a pediatric multidisciplinary clinic were examined. Main Outcomes and Measures: The main outcomes studied were changes in admissions and inpatient days before and after enrollment. Financial data were also examined to determine the reduction in technical direct cost. Results: The admissions data for 113 children were analyzed. No significant difference in number of admissions per year was seen with enrollment with a median difference of -0.30 admissions per year (range, -10.6 to 6.7 admissions per year; 95% CI, -3.5 to 2.9). However, there was a significant decrease seen in inpatient days per year following enrollment, with a median decrease of 4.1 inpatient days per year (range, -80 to 283.3 inpatient days per year; 95% CI, 0.33 to 91.0). When examining aerodigestive admissions alone, the median number of aerodigestive hospital days avoided per patient was 0.57 days per month, or 6.8 days per year, representing a 70% reduction in technical direct cost. Conclusions and Relevance: These findings indicate that for children with special health care needs, enrollment in a multidisciplinary aerodigestive clinic may improve health care outcomes by decreasing technical direct cost by 70% and significantly decreasing patient hospital days by an estimated 1 week per year. Furthermore, coordinated aerodigestive care in a medical home setting may lower health care expenditures from a systems-based perspective.

Nasal septal abscess in association with pediatric acute rhinosinusitis.

INTRODUCTION: Nasal septal abscess (NSA) in the pediatric population is rare and can result in devastating complications. Objective of this study is to review a case series of pediatric patients presenting with NSA in association with acute rhinosinusitis (ARS) for possible risk factors and predisposing conditions. METHOD: This is a retrospective review of pediatric patients that presented to a tertiary care hospital with nasal septal abscess associated with ARS. Patient demographics, presence of ARS, sinuses involved, and other potential risk factors were recorded. In addition, a literature review was conducted to evaluate other reported cases of NSA in association with ARS. Cases of NSA associated with trauma or other causes were excluded from analysis. RESULTS: Five patients with NSA were treated by the pediatric otolaryngology department of a tertiary care center from 2003 to 2014. Three of these cases were associated with ARS. Of these cases, the average age at diagnosis was 9.7 years. Two were male and one was female. In these cases, the bilateral frontal, maxillary and ethmoid sinuses were involved. Sphenoid involvement occurred in two patients. One case was associated with ipsilateral middle turbinate concha bullosa. The cartilaginous septum was compromised in all three cases. All patients were treated with incision and drainage. CONCLUSION: This is the largest case series of NSA described in the pediatric population. NSA is exceedingly rare but may be associated with ARS. While the etiology of NSA is not always clear, identifying and treating nasal septal abscesses early is imperative to reduce potentially devastating complications.

Nystagmus in Enlarged Vestibular Aqueduct: A Case Series.

Enlarged vestibular aqueduct (EVA) is one of the commonly identified congenital temporal bone abnormalities associated with sensorineural hearing loss. Hearing loss may be unilateral or bilateral, and typically presents at birth or in early childhood. Vestibular symptoms have been reported in up to 50% of affected individuals, and may be delayed in onset until adulthood. The details of nystagmus in patients with EVA have not been previously reported. The objectives were to describe the clinical history, vestibular test findings and nystagmus seen in a case series of patients with enlarged vestibular aqueduct anomaly. Chart review, included computed tomography temporal bones, infrared nystagmography with positional and positioning testing, caloric testing, rotary chair and vibration testing. Clinical history and nystagmus varied among the five patients in this series. All patients were initially presumed to have benign paroxysmal positional vertigo, but repositioning treatments were not effective, prompting referral, further testing and evaluation. In three patients with longstanding vestibular complaints, positional nystagmus was consistently present. One patient had distinct recurrent severe episodes of positional nystagmus. Nystagmus was unidirectional and horizontal. In one case horizontal nystagmus was consistently reproducible with seated head turn to the affected side, and reached 48 d/s. Nystagmus associated with enlarged vestibular aqueduct is often positional, and can be confused with benign paroxysmal positional vertigo. Unexplained vestibular symptoms in patients with unilateral or bilateral sensorineural hearing loss should prompt diagnostic consideration of EVA.

Pediatric maxillary and mandibular tumors.

Pediatric maxillary and mandibular tumors offer considerable challenges to otolaryngologists, oral surgeons, pathologists, and radiologists alike. Because of the close proximity to vital structures, appropriate steps toward a definitive diagnosis and treatment plan are of paramount importance. This article reviews the most common causes of pediatric jaw masses and discusses diagnostic and therapeutic considerations and recommendations.

Rhinosinusitis in children: a comparison of patients requiring surgery for acute complications versus chronic disease.

BACKGROUND: Patient characteristics, risk factors, and microbiology are important to consider in the management of complications of acute bacterial sinusitis (ABS) in pediatric patients. This study evaluates this subset of patients and compares them to patients that undergo surgery for chronic rhinosinusitis (CRS). METHODS: This study is a retrospective review of all pediatric patients from 2002 to 2011, who underwent sinus surgery at a tertiary hospital. Patients who underwent surgery for ABS complication were compared to patients who underwent surgery for CRS. Statistical analysis was completed using chi-square test or Fisher's exact test with a statistical significance set at p<0.05. RESULTS: Twenty-seven patients with a complication of ABS and 77 patients with CRS were analyzed. The groups did not differ demographically. Patients with a complication were statistically less likely to have seasonal allergies, prior sinusitis, prior nasal steroid use, or adenoidectomy (p<0.05). In addition, they had more frequent involvement of ethmoid and frontal sinuses (p<0.05). The most common cultures results were no growth (30.8%), Streptococcus milleri (30.8%), and normal flora (19.2%) in ABS for the with a complication group, and normal flora (41.5%), coagulase negative Staphylococcus (22%), and Propionobacterium (19.5%) for the CRS group. Most prevalent complications were preseptal cellulitis (55.5%), orbital subperiosteal abscess (29.6%), subgaleal abscess (22%), and epidural abscess (22%). Five patients had simultaneous orbital and intracranial complications. CONCLUSIONS: Patients who present with complications of ABS vary significantly from the CRS patients. Location of most commonly affected sinuses and microbiology also differ and is crucial for understanding the management of this disease process.

Patient satisfaction in pediatric surgical care: a systematic review.

OBJECTIVE: This study seeks to synthesize evidence-based findings related to patient satisfaction as a process measure in pediatric surgical care. DATA SOURCES: PubMed, CINAHL, Scopus, and the Cochrane Central Register of Controlled Trials. REVIEW METHODS: We queried 4 standard search engines (1992-2013) for studies specific to pediatric surgical fields in which patient or parent satisfaction or experience of care was a primary outcome measure. Data were systematically analyzed to determine study characteristics, setting, parent or patient focus, measure of experience, and bias. Two independent investigators independently reviewed all articles. RESULTS: The initial search yielded 4748 publications (1503 duplicates), of which 170 underwent full-text review. Thirty-five were included for analysis; the majority (24/35,77%) were published in the last 5 years. Studies examined experience of the child (3/35), parent (23/35), or both (9/35). Experience and satisfaction were evaluated either by validated self-assessment instruments (8), by satisfaction tools (8), or by nonstandard institutional or author-developed tools (19). Experience was measured in the outpatient (7), preoperative (11), operative (14), and postoperative (3) care settings. Specific findings were unique to setting; however, in many studies higher satisfaction correlated with education/information giving, health care provider interpersonal behaviors, and facile/efficient care processes. CONCLUSION: The patient experience of care is a valuable quality measure that is being more frequently evaluated as a mechanism to improve pediatric surgical care processes. Findings related to patient satisfaction and experience of care may be limited due to lack of measurement using validated tools. Findings from this review may bear significance as patient experience measures become routinely integrated with quality and reimbursement.

Enlarged neck lymph nodes in children.

Pediatric cervical lymphadenopathy is a challenging medical condition for the patient, family, and physician. There are a wide variety of causes for cervical lymphadenopathy and an understanding of these causes is paramount in determining the most appropriate workup and management. A thorough history and physical examination are important in narrowing the differential diagnosis. Diagnostic studies and imaging studies play an important role as well. This article reviews the common causes of lymphadenopathy, and presents a methodical approach to a patient with cervical lymphadenopathy.

Ultrasound characterization of middle ear effusion.

PURPOSE: To further enhance and assess the ability to characterize middle ear effusion (MEE) using non-invasive ultrasound technology. MATERIALS AND METHODS: This is a prospective unblinded comparison study. Fifty-six children between the ages of 6 months and 17 years scheduled to undergo bilateral myringotomy with pressure equalization tube placement were enrolled. With the child anesthetized, the probe was placed into the external ear canal after sterile water was inserted. Ultrasound recordings of middle ear contents were analyzed by computer algorithm. Middle ear fluid was collected during myringotomy and analyzed for bacterial culture and viscosity. RESULTS: Ultrasound waveforms yielded a computer algorithm interpretation of middle ear contents in 66% of ears tested. When a result was obtained, the sensitivity and specificity for successfully characterizing middle ear fluid content as either void of fluid, thick fluid (mucoid), or thin fluid (serous or purulent) were at least 94%. Mucoid effusions had higher measured viscosity values (P=.002). Viscosity measures were compared to culture result, and those with low viscosity (thin consistency) had a higher likelihood of having a positive culture (P=.048). CONCLUSION: The device sensitivity and specificity for fluid detection were 94% or greater among interpretable waveforms (66% of those tested). Although this technology provides important information of the middle ear effusion presence and characteristic, further technological improvements are needed.

Clinical consensus statement: appropriate use of computed tomography for paranasal sinus disease.

OBJECTIVE: To develop a consensus statement on the appropriate use of computed tomography (CT) for paranasal sinus disease. SUBJECTS AND METHODS: A modified Delphi method was used to refine expert opinion and reach consensus by the panel. RESULTS: After 3 full Delphi rounds, 33 items reached consensus and 16 statements were dropped because of not reaching consensus or redundancy. The statements that reached consensus were grouped into 4 categories: pediatric sinusitis, medical management, surgical planning, and complication of sinusitis or sinonasal tumor. The panel unanimously agreed with 13 of the 33 statements. In addition, at least 75% of the panel strongly agreed with 14 of 33 statements across all of the categories. CONCLUSIONS: For children, careful consideration should be taken when performing CT imaging but is needed in the setting of treatment failures and complications, either of the pathological process itself or as a result of iatrogenic (surgical) complications. For adults, imaging is necessary in surgical planning, for treatment of medical and surgical complications, and in all aspects of the complete management of patients with sinonasal and skull base pathology.