Characteristics of COVID-19 smell and taste dysfunction in hospitalized patients.

The effects of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) exist on a spectrum. Clinical symptoms of smell and taste dysfunction are prominent features of COVID-19. The objective of this study was to elucidate the factors associated with smell and taste dysfunction amongst hospitalized COVID-19 patients. A retrospective review of a multi-hospital health network's COVID-19 database between March and June 2020 was performed. Patients with self-reported smell or taste loss were included. Demographic information, patient comorbidities, and mortality data was obtained. There were 2892 patients included in this analysis and 117 reported smell or taste loss (4.0%, 95% confidence interval [CI]: 3.4%-4.8%). The proportion of females with smell or taste loss was significantly higher than males (6.3% vs. 2.5%, P < 0.001), whereas no differences existed between ethnicity or smoking status. When compared with age of 30-40 years, the age group of 10-20 years were most likely to present with smell or taste dysfunction (odds ratio [OR] 6.59, 95% CI 1.32-26.12; P = 0.01). The majority of specific comorbidities were not associated with increased incidence of smell or taste dysfunction. Outpatient healthcare workers were more likely to present with smell or taste loss (OR 3.2, CI 1.8-5.47; P < 0.001). The mortality rate among COVID-19 patients with smell or taste dysfunction was significantly lower than those without (0% vs. 20.3%; P < 0.001). Smell or taste loss is more prevalent in women, younger age groups, and healthier individuals. It may be associated with lower mortality and a milder disease trajectory compared to the overall cohort.

Elective neck dissection (END) and cN0 hard palate and upper gingival cancers: A National Cancer Database analysis of factors predictive of END and impact on survival.

BACKGROUND AND OBJECTIVES: The reported risk of nodal metastasis in hard palate and upper gingival squamous cell carcinoma (SCC) has been inconsistent with inadequate consensus regarding the utility of neck dissection in the clinically negative (cN0) neck. MATERIALS AND METHODS: Using the National Cancer Database, cN0 patients diagnosed with SCC of the head and neck with the subsites of the hard palate and upper gingiva were identified from 2004 to 2014. RESULTS: A total of 1830 patients were identified, and END was performed on 422 patients with cN0 tumors. Pathologically positive nodes occurred in 14% (59/422) of patients in this cohort. Higher tumor stage, academic hospital type, and large hospital volume (>28 cancer-specific cases/year) were associated with a higher likelihood of END both in univariate and multivariate analyses (P < .05). Patients >80 years of age were less likely to receive END on multivariate analysis (OR 0.52, 0.32-0.84). No variables, including advanced T stage, predicted occult metastases. Cox proportional hazards regression analysis showed that patients who underwent END demonstrated improved OS over an 11-year period (hazard ratio 0.75, P = .002). On subgroup analysis, this improvement was significant in patients with both stage T1 and T4 tumors. CONCLUSIONS: Tumor stage, hospital type, and hospital volume were associated with higher rates of END for patients with cN0 hard palate SCC and after controlling for clinical factors, END was associated with improved overall survival.

Comparing Kadish, TNM, and the modified Dulguerov staging systems for esthesioneuroblastoma.

BACKGROUND: Esthesioneuroblastoma (ENB) is a rare neuroendocrine tumor. The purpose of this study was to compare the Kadish, tumor-node-metastasis (TNM), and Dulguerov's modified TNM staging in order to determine the impact of the stage on primary surgical treatment selection, margin status, and survival. METHODS: The National Cancer Database (NCDB) was used to identify patients diagnosed with ENB between 2004 to 2015. Patients were excluded based on the ability to properly stage their disease as well as the availability of treatment data. RESULTS: Eight-hundred eighty-three patients had sufficient data for analysis. On multivariate analysis, age and government insurance were associated with primary surgical treatment, whereas tumor stage, gender, race, hospital type and volume, and comorbidity score were not. Age, charlson-deyo comorbidity (CDCC) score, hospital volume, and nodal status were found to be predictors of survival. Multivariate-analysis controlling for stage failed to demonstrate clear survival differences between staging in both TNM and Kadish systems. T-stage and the presence of regional nodal metastasis were associated with an increased risk of positive margins on multivariate analysis. CONCLUSION: Although primary surgical management and positive margins can be predicted by certain patient and tumor factors, clinical staging systems for ENB poorly predict prognosis over a 10-year horizon.

Transoral Finger-Retraction for Endonasal Endoscopic Resection of Masseteric and Buccal Space Lesions.

Lesions involving the masseteric and buccal spaces have traditionally required transoral or transcervical approaches. Herein, the authors describe the successful endonasal endoscopic resection of a juvenile nasopharyngeal angiofibroma (JNA) with significant extension into the masseteric and buccal spaces facilitated by transoral finger retraction. Juvenile nasopharyngeal angiofibromas are hypervascular tumors originating in the pterygopalatine fossa (PPF) with complex relationships to skull base and orbital structures. Endoscopic approaches have allowed for resection of JNAs with excellent visualization and without traditional transfacial approaches, decreasing morbidity and reducing incidence of facial deformity with similar outcomes as open approaches. While the endonasal endoscopic approach to the masseteric and buccal spaces is unconventional, encapsulated tumors in these regions can be delivered into the nasal cavity through the maxilla and PPF with the use of transoral finger-retraction. The authors present a case of a 10-year-old male referred to their tertiary care center with left-sided epistaxis, nasal obstruction, and facial swelling. Imaging demonstrated a vascular lesion in the PPF involving the left nasal cavity and paranasal sinuses, with extension into left middle cranial fossa, infratemporal fossa, orbit, and deep spaces of the neck including the masticator, masseteric, and buccal spaces. The patient underwent preoperative embolization and endoscopic endonasal surgical resection with transoral finger-retraction without complication. Transoral finger-retraction represents a supplemental technique that allows for encapsulated lesions involving the masseteric and buccal spaces to be delivered into the nasal cavity for endoscopic resection in a safe and effective fashion, preventing the need for transfacial incisions.

Understanding and clinical relevance of chronic rhinosinusitis endotypes.

BACKGROUND: Chronic rhinosinusitis (CRS) is the downstream manifestation of heterogeneous pathophysiologic mechanisms leading to chronic sinonasal inflammation. Traditional grouping of patients by symptoms or clinical findings/phenotypes is being replaced by classification of CRS patients based on the underlying pathophysiologic mechanisms: endotypes. OBJECTIVE OF REVIEW: To provide an up-to-date review on the current knowledge of CRS endotypes with a focus on how the pathophysiologic mechanisms defined by each endotype may be targeted therapeutically. Special emphasis is placed on the clinical relevance of the material and how it may inform the current practice of otolaryngologists. TYPE OF REVIEW: A systematic review of contemporary literature review focusing on the latest studies examining the role of endotypes in the management and treatment of CRS. SEARCH STRATEGY: A MEDLINE and PubMed Central search were undertaken to perform this review using the keywords "Endotype" and "Sinusitis." EVALUATION METHOD: Articles containing the keywords, as well as the references of those articles, were then examined for relevance. RESULTS: The endotypes for CRS are often defined based on the balance of T-helper cell patterns of inflammation and can be grouped into Th2 and non-Th2 inflammation. These groups have shown a variable response to medical and surgical therapy, demonstrating that existing mainstream treatments can be tailored to patients with specific endotypes. The inflammatory mediators of Th2 inflammation, IL-4, IL-5 and IL-13 as well as IgE, are targeted by available biologic drugs that can be used for treatment of refractory disease. CONCLUSIONS: Increased understanding of CRS endotypes has led to the identification of biomarkers that define these endotypes and act as targets for potential therapeutics. Increasing knowledge about characteristics associated with these endotypes and their responses to treatments, including both established mainstream CRS treatments and novel biologic medications, has allowed incorporation of CRS endotypes into the current clinical decision-making. Treatment of CRS patients based on consideration of their endotypes is therefore not only presently possible but may improve clinical outcomes of those patients as well.

The Interobserver and Intraobserver Reliability of the Sanders Classification Versus the Risser Stage.

BACKGROUND: Estimation of skeletal maturity, classically performed using Risser sign, plays a crucial role in the treatment of AIS. Recent data, however, has shown the simplified Tanner-Whitehouse (Sanders) classification, based on an anteriorposterior (AP) hand radiographs, to correlate more closely to the rapid growth phase and thus curve progression. This study evaluated the interobserver and intraobserver reliability of the Sanders and Risser classifications among clinicians at different levels of training. METHODS: Twenty AP scoliosis radiographs and 20 AP hand radiographs were randomized and distributed to 11 graders. The graders consisted of 3 orthopaedic residents, 3 spine fellows, 3 spine surgeons, and 1 radiologist. The graders were then asked to classify the radiographs according to the Sanders and Risser classifications. There were 3 rounds of grading, each done 3 weeks apart. The overall κ coefficient was then calculated for each system to evaluate the interobserver and intraobserver reliability. RESULTS: For all graders the average κ coefficient for the interobserver and intraobserver reliability of the Sanders classification was 0.54 and 0.62, respectively, and 0.46 and 0.49 for the Risser classification. With respect to spine attendings alone, the average κ coefficient for the interobserver and intraobserver reliability of Sanders classification was 0.72 and 0.77, respectively, and 0.46 and 0.67 for the Risser classification. CONCLUSIONS: Our study demonstrated that the Sanders classification had moderate reliability with respect to physicians at various levels of training and had good reliability with respect to attending spine surgeons. Interestingly, the Risser staging was found to have less interobserver and intraobserver reliability overall. The Sanders classification is a reliable and reproducible system and should be in the armamentarium of surgeons who treat adolescent idiopathic scoliosis. LEVEL OF EVIDENCE: Level III.

The association between scholarly impact and National Institutes of Health funding in ophthalmology.

OBJECTIVE: To examine whether there is an association between scholarly impact, as measured by the h-index, academic rank, and National Institutes of Health (NIH) awards in academic ophthalmology. DESIGN: Retrospective analysis of NIH RePORTER and Scopus databases. PARTICIPANTS: Not applicable. METHODS: Five hundred seventy-three NIH awards to 391 primary investigators (PIs) in ophthalmology departments were examined. Grant recipients were organized by academic rank, obtained from online listings, and h-index, calculated using the Scopus database. Non-NIH-funded faculty from 20 randomly chosen academic ophthalmology departments also were organized by rank and h-index for comparison with their NIH-funded colleagues. MAIN OUTCOME MEASURES: Scholarly impact, as measured by the h-index, and NIH funding. RESULTS: The h-index increased with successive academic rank among non-NIH-funded and NIH-funded faculty, as did NIH funding among the latter group. The NIH-funded faculty had higher scholarly impact, as measured by the h-index, than their non-NIH-funded PIs (h = 18.3 vs. 7.8; P <0.0001), even when considering publications only in the prior 5 years; h-index increased with increasing NIH funding ranges. The h-indices of those holding an MD degree (21.4±1.6 standard error of mean) were not statistically higher than those of PhD holders (17.9±0.6) and those with both an MD and PhD degree (18.1±1.7; P = 0.14). CONCLUSIONS: The h-index increases with increasing academic rank among NIH-funded and non-NIH-funded faculty in ophthalmology departments. This bibliometric is associated strongly with NIH funding because NIH-funded PIs had higher scholarly impact than their non-NIH-funded colleagues, and increasing impact was noted with higher funding. The h-index is an objective and easily calculable measure that may be valuable as an adjunct in assessing research productivity, a significant factor for academic promotion in academic ophthalmology.

Management of sinonasal teratocarcinosarcoma: a systematic review.

PURPOSE: Sinonasal teratocarcinosarcoma (SNTCS) is a rare and highly malignant neoplasm that often involves the anterior skull base. This study reviews the published literature related to SNTCS. Clinical presentation, demographics, radiographic diagnosis, pathology, treatment, and management outcomes of this uncommon disease are reported. METHODS: A systematic review in the published English literature was conducted. A MEDLINE/PubMed search and bibliographic examination of articles pertaining to SNTCS were performed. Each case was analyzed for patient demographics, clinical presentation, tumor location, diagnosis, treatment, and survival outcome. RESULTS: A total of 49 journal articles were included. Individual patient data were reported in 86 cases. The average age of the patients was 54.5 years (range, 0.1 to 85 years), with a strong male predilection (7:1). Average follow-up was found to be 38.9 months (range, 2 to 372 months). The most common treatment method was surgery with radiation therapy, utilized in 59.3% of patients. Out of 71 cases with reported outcome and follow-up, there were 21 cases of recurrence, 8 cases with metastasis, and 6 cases reporting both recurrence and metastasis. Forty-two out of 71 (59.2%) patients survived at the time of follow-up. CONCLUSIONS: This study describes the largest pool of SNTCS patients to date. SNTCS is a rare and aggressive malignant skull base tumor with a poor prognosis with frequent recurrence and metastasis. Although a variety of treatment paradigms have been reported in the literature, radical surgical resection followed by radiation therapy appears to be the most commonly used treatment option.

In the eyes of the law: malpractice litigation in oculoplastic surgery.

PURPOSE: To assess characteristics associated with various outcomes of malpractice litigation, resulting from injuries sustained during oculoplastic procedures. METHODS: The Westlaw legal database (Thomson Reuters, New York, NY, U.S.A.) was used to obtain jury verdicts and settlements. Pertinent data were extracted from 69 malpractice cases litigated from 1988 to 2012 involving oculoplastic procedures, including alleged cause of malpractice, outcome, and defendant specialty. RESULTS: The most commonly litigated surgical procedures were blepharoplasty (63.8% of total) and brow lift surgery (11.6%). The most commonly alleged complications included excessive scarring (24.6%), lagophthalmos (24.6%), visual defects (23.2%), and exposure keratitis (21.7%). Plastic surgeons were the most commonly named defendants (46.4%), followed by both comprehensive ophthalmologists and fellowship-trained ophthalmic plastic surgeons (17.3% each). A defense verdict was held in 60.9% of cases, a plaintiff verdict in 31.9% of cases, and a settlement was reached in 7.2% of cases. Blindness, cranial nerve injury, and the allegation of a permanent deficit increased the likelihood of a case being resolved with payment to the plaintiff (Fisher exact tests, p < 0.05). CONCLUSIONS: Most litigated oculoplastic malpractice cases were resolved in favor of the defendant, while settlements and plaintiff decisions averaged $455,703. Blepharoplasty constituted two-thirds of cases, with the most frequently cited associated complications being unsightly scarring, lagophthalmos, and visual deficits. An alleged lack of informed consent (30.4%) or the need for additional surgery (39.1%) was present in a considerable proportion of cases, emphasizing the importance of a detailed informed consent and clear communication preoperatively regarding patient expectations.

Determining legal responsibility in otolaryngology: a review of 44 trials since 2008.

PURPOSE: Medicolegal factors contribute to increasing healthcare costs through the direct costs of malpractice litigation, malpractice insurance premiums, and defensive medicine. Malpractice litigation trends are constantly changing as a result of technological innovations and changes in laws. In this study, we examine the most recent legal decisions related to Otolaryngology and characterize the factors responsible for determining legal responsibility. METHODS: The Westlaw legal database (Thomson Reuters, New York, NY) was used to search for jury verdicts since 2008 in Otolaryngology malpractice cases. The 44 cases included in this analysis were studied to determine the procedures most commonly litigated and progressing to trial, as well as the year, location, alleged cause of malpractice, specialty of co-defendants, and case outcomes. RESULTS: Out of the 44 cases included in this analysis, physicians were not found liable in 36 (81.8%) cases. Rhinologic procedures comprised 38.6% of cases litigated, and rulings were in physicians' favor in 66.7% of endoscopic sinus surgery (ESS) cases and all non-ESS rhinologic cases. A perceived lack of informed consent was noted in 34.1% of cases. The 8 jury awards averaged $940,000 (range, $148,000-$3,600,000). CONCLUSION: Otolaryngologists were not found liable in the majority of cases reviewed. Rhinologic surgeries were the most common procedures resulting in litigation. Adenotonsillectomies, thyroidectomies, and airway management are also well-represented. Perceived deficits in informed consent and misdiagnosis were noted in a considerable proportion of otolaryngologic malpractice cases resulting in jury decisions.

Geographic differences in academic promotion practices, fellowship training, and scholarly impact.

PURPOSE: Previous literature described how clinical fellowship training impacts scholarly production among academic otolaryngologists, finding that fellowship-trained practitioners had higher research productivity than their non-fellowship-trained peers, and head and neck (H&N) surgeons and otologists had the highest scholarly impact. In this analysis we investigate whether geographic differences in academic promotion and scholarly impact exist, and whether such differences are associated with emphasis on regional fellowship training patterns. METHODS: The Scopus database was used to determine scholarly impact (as measured by the h-index) of 1109 academic otolaryngologists from 97 departments. Online faculty listings were organized by fellowship training, academic rank, and location. RESULTS: Fellowship-trained practitioners had greater research productivity than non-fellowship-trained otolaryngologists (H=9.5 ± 0.26 SEM vs. 6.5 ± 0.43, p<0.001), a finding that persisted throughout except in the Mountain and East South Central Regions. H&N surgeons and otologists had the highest h-indices. Practitioners in the West had the highest h-index, with differences persisting upon examination of junior faculty. The West (62.1%) and Midwest (60.5%) had the highest proportions of senior faculty. Regional differences in scholarly impact and academic promotion were further noted upon organizing faculty by subspecialty fellowship training. CONCLUSIONS: Geographic differences in academic promotion and scholarly impact exist, most markedly among junior faculty. Practitioners in the West had high impact and were more represented at senior ranks. Upon examination by fellowship training status, fellowship-trained otolaryngologists had higher impact in most, but not all, geographic regions. Regional variations in promotion were noted upon organizing faculty by subspecialty, although association with scholarly impact differs by region.

Norman Dott, Gerard Guiot, and Jules Hardy: key players in the resurrection and preservation of transsphenoidal surgery.

Developed over a century ago, the transsphenoidal approach to access lesions of the pituitary gland and sella turcica has transformed the field of neurosurgery, largely due to the work of Oskar Hirsch and Harvey Cushing. Furthermore, its use and modification in the early 1900s was perhaps one of Cushing's greatest legacies to skull base surgery. However, Cushing, who had worked relentlessly to improve the transsphenoidal route to the pituitary region, abandoned the approach by 1929 in his pursuit to master transcranial approaches to the suprasellar region. Hirsch and a few other surgeons continued to perform transsphenoidal operations, but they were unable to maintain the popularity of the approach among their peers. During a time when transsphenoidal surgery was on the brink of extinction, a critical lineage of 3 key surgeons--Norman Dott, Gerard Guiot, and Jules Hardy--would resurrect the art, each working to further improve the procedure. Dott, Cushing's apprentice from 1923 to 1924, brought his experiences with transsphenoidal surgery to Edinburgh, Scotland, and along the way, developed the lighted nasal speculum to provide better illumination in the narrow working area. Guiot, inspired by Dott, adopted his technique and used intraoperative radiofluoroscopic technique for image guidance. Hardy, a fellow of Guiot, from Montreal, Canada, revolutionized transsphenoidal microsurgery with the introduction of the binocular microscope and selective adenomectomy. The teachings of these pioneers have endured over time and are now widely used by neurosurgeons worldwide. In this paper, we review the lineage and contributions of Dott, Guiot, and Hardy who served as crucial players in the preservation of transsphenoidal surgery.

Jugular Bulb Anomalies Involving the Internal Auditory Canal: A Case Series.

OBJECTIVE: Jugular bulb abnormalities (JBA) such as high riding jugular bulb and jugular bulb diverticulum can extend or erode into the middle and inner ear. In this report, we report on a series of 6 patients with jugular bulb anomalies involving the internal auditory canal (IAC). METHODS: A retrospective case series. RESULTS: Six females, ages 6 to 63 presenting with myriad of otologic symptoms including hearing loss, tinnitus, balance disturbance, fullness, and otalgia were discovered to have JB eroding into IAC. Computerized tomography, but not Magnetic Resonance Imaging, was able to identify IAC erosion by a significantly enlarged JB. CONCLUSION: A significantly enlarged JB eroding into the IAC maybe congenital or acquired. It can present with a variety of common otologic symptoms. Long term follow-up is needed to determine the natural history of JB anomalies involving the IAC and need for intervention.

Lynch vs transcaruncular approach: optimizing access to the lateral frontal sinus.

BACKGROUND: Visualization and instrumentation of the frontal sinus is not always possible with a Draf III or modified endoscopic Lothrop procedure (MELP), and external incisions can help augment exposure. We compare lateral frontal sinus access using only a MELP compared to the adjunctive transcaruncular approach and transcutaneous Lynch incision. METHODS: Twelve cadaveric heads underwent thin-cut computed tomography scanning. Measurement of the frontal beak, anteroposterior depth of the frontal sinus, and interorbital distance was performed. There were 4 specimens with poorly pneumatized frontal sinuses that were excluded from the study. Eight cadaveric heads (16 sides) were dissected and a MELP with bilateral transcaruncular and Lynch incisions for access to the lateral frontal sinus was performed. Under image guidance, measurements extended from the midline crista galli to the most lateral point of the frontal sinus visualized using a 0-degree endoscope with straight suction and a 30-degree endoscope with curved suction. RESULTS: The proportion of the ipsilateral frontal sinus accessed through the contralateral nare with a 0-degree endoscope and straight suction using a MELP only, a MELP with transcaruncular approach, and a MELP with Lynch incision, respectively, averaged 41.6%, 51.6%, and 58.9% on the right, and 48.9%, 47.1%, and 61.2% on the left. Using a 30-degree endoscope and curved suction the proportion accessed using a MELP only, a MELP with transcaruncular approach, and a MELP with Lynch incision, respectively, increased to 76.1%, 62.6%, and 91.8% on the right, and 83.2%, 62.7%, and 88.7% on the left. CONCLUSION: Adjunctive external approaches can improve access and instrumentation of the frontal sinus when combined with a MELP.

Endoscopic endonasal intraconal orbit surgery.

Endoscopic endonasal orbital surgery is evolving. With increasing knowledge, expertise, and technology, the historical limits of the endonasal endoscopic approach to the orbit have been redefined. This review discusses the clinical presentation and etiology, and highlights the pertinent anatomy, and discusses the diagnostic workup and surgical approach to orbital tumors and post-operative care. The role of the multidisciplinary team is not to be underestimated. The introduction of a classification system to ensure standardization of technical difficulty and outcome data will assist with international collaboration and further consolidate our attainment of knowledge in this developing field.

Nonopioid Adjuncts and Alternatives.

Multimodality nonopioid analgesia can be effective for pain control. Balancing risks and benefits of treatment should guide the appropriateness of opioid versus nonopioid pain control.

Lightening in a bottle: comparison of ultraviolet light to traditional sterilization in saline irrigations bottles.

BACKGROUND: Nasal saline irrigations (NSIs) are commonplace in treatment of patients with sinonasal disorders. Contamination of both the water source and delivery bottle remains a challenge with this therapy. The goal of this study was to optimize a disinfection technique with various methods of preparation, disinfection, and delivery of NSIs. METHODS: Distilled and tap water sources in NSI bottles were contaminated by 4 bacterial strains: Bacillus subtilis, Staphylococcus aureus, Pseudomonas aeruginosa, and Legionella pneumophila. Contaminated bottles were cleaned with tap water, tap water with detergent, or microwave and swabbed for culture. Water-source disinfection was performed with reverse osmosis, distillation, activated carbon filtration, boiling, or ultraviolet (UV) light treatment. Test samples from each experimental group (n = 3/group) were cultivated on the appropriate media with colony-forming units (CFUs) reported. RESULTS: All methods of bottle cleaning with tap water with/without detergent and microwave significantly reduced bacterial load (CFUs) by >99% (p < 0.05). Distillation and boiling of the contaminated water source eliminated 100% of bacteria, whereas reverse osmosis and activated carbon filtration did not. A single UV treatment of contaminated water within a bottle eliminated 99% of bacteria within the water and 100% in the bottle. CONCLUSION: Cleansing of NSI bottles with tap water with/without detergent or microwave produced robust bacterial disinfection. Distillation and boiling of a contaminated water source completely eliminated all bacteria. UV light treatment was capable of simultaneous disinfection of both the water source and bottle, suggesting this may be a convenient, 1-step method of preparing NSIs for patients.

The role of routine nasolacrimal sac biopsy during endoscopic dacryocystorhinostomy.

OBJECTIVES/HYPOTHESIS: Most patients who undergo endoscopic dacryocystorhinostomy (DCR) have a diagnosis of idiopathic nasolacrimal duct obstruction. The purpose of this study was to examine the impact of routine biopsy of the lacrimal sac performed at time of DCR on subsequent patient diagnosis and treatment. STUDY DESIGN: Retrospective review. METHODS: The histopathology of nasolacrimal specimens (n = 769), obtained from 654 consecutive patients undergoing endoscopic DCR by a single surgeon over a 30-year period, were reviewed. Specific focus included the identification of unanticipated pathologic findings as they related to pertinent patient demographics, clinical presentation, radiologic findings, and intraoperative observations. RESULTS: The study population was 69.6% female, with an average age of 56.1 ± 18.2 years. Pathological findings of tissue from the nasolacrimal sac, which was routinely sampled in all cases, showed inflammation (n = 566 [73.6%]), normal histology (n = 147 [19.1%]), granulomas (n = 8 [1.0%]), and neoplastic process (n = 7 [0.9%]). Patient history, preoperative CT scan, and/or intraoperative findings alerted the surgeon to the possibility of an unusual diagnosis in 12 of the 15 patients. An unsuspected neoplastic or granulomatous cause of lacrimal obstruction was identified on intraoperative biopsy in three patients (0.46%). CONCLUSIONS: Although neoplastic and granulomatous diseases are relatively rare causes of lacrimal obstruction necessitating DCR surgery, they may be identified by through patient evaluation in most cases and by routine intraoperative biopsy of the lacrimal sac in all cases. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:584-589, 2020.

Endoscopic endonasal approaches to the craniovertebral junction: The Otolaryngologist's perspective.

OBJECTIVE: To review indications and techniques for the endoscopic endonasal approach to the craniovertebral junction (CVJ), analyze postoperative outcomes, and discuss important technical considerations. METHODS: A retrospective analysis was performed on all patients undergoing endonasal endoscopic approaches to the CVJ from May 2007 to June 2017. Demographic information, presenting symptoms, imaging results, treatment course, postoperative functional status, and follow-up were recorded. RESULTS: There was a total of 30 patients in this series, with a mean follow-up of 11.7 months. The average age was 33.6 years (range, 5-75 years), with 18 females and 12 males. The majority of patients (n = 22, 73.3%) had Chiari malformation type 1 with basilar invagination and symptomatic cervicomedullary compression as the indication for surgery. Intraoperative cerebrospinal fluid leak (CSF) was noted in 3 cases of odontoid resection and a single case of skull base resection. There were no postoperative CSF leaks. Overall, 81% of patients resumed regular diet by post-operative day 2 (range, 0-8 days). Severe postoperative dysphagia occurred in two cases with one requiring gastrostomy tube placement and another utilizing total parenteral nutrition for support prior to eventual gastrostomy. On average, patients were extubated by postoperative day 0.93 (range 0-3 days), with 85% extubated by postoperative day 1. A tracheotomy was required in one patient. CONCLUSION: The endonasal endoscopic approach is a valuable technique for access to the CVJ with minimal disruption of respiratory and alimentary function.