Multiple skull base defects in the setting of spontaneous cerebrospinal fluid rhinorrhea; a dual institution view.

PURPOSE: Idiopathic intracranial hypertension (IIH) is a condition of high cerebrospinal fluid (CSF) pressure that presents with CSF leak. The implications of multiple skull base defects (SBD) and associated synchronous CSF leaks have not been previously explored. MATERIALS AND METHODS: A dual institutional case-control study examined multiple SBD's and encephaloceles on the risk of CSF leak and postoperative failures post-repair. IIH patients with CSF leaks and IIH controls without leaks were selected retrospectively. Chi square analysis evaluated for statistically significant alterations in probability with CSF leak development. RESULTS: 192 patients were selected with 108 IIH controls and 84 spontaneous CSF leak cases. Signs and symptoms for IIH controls and CSF leak cases respectively were pulsatile tinnitus (60.2 % and 29.8 %), headaches (96.3 % and 63.1 %), papilledema (74.1 % and 12.5 %), visual field defects (60.8 % and 13 %) (p < 0.001). Encephalocele formation in controls was 3.7 % compared to cases at 91.6 % (p < 0.001). Multiple SBD's in controls compared cases was 0.9 % and 46.4 % respectively (p < 0.001). Subgroup analysis of CSF leak cases showed 15 patients with two CSF leak repairs due to a recurrence. 27 (39.1 %) single leak cases had multiple SDB's while 12 (80 %) recurrent leaks had multiple SDB's (p = 0.004). CONCLUSIONS: Patients with radiographic evidence of multiple SBD's and encephaloceles represent a high-risk population with a propensity for CSF leaks. Secondary SBD's are common in patients with spontaneous CSF rhinorrhea and higher in patients with a recurrence.

Race and ethnicity define disparate clinical outcomes in chronic rhinosinusitis.

BACKGROUND: Chronic rhinosinusitis (CRS) is a common upper airways inflammatory disease requiring multidisciplinary care. OBJECTIVE: To evaluate if African Americans (AA), Latinxs, and nonLatinx White (White) patients have different chronic rhinosinusitis outcomes and to identify associated factors impacting these outcomes. METHODS: We conducted a large prospective cohort study of CRS patients who were evaluated and followed for several clinical variables at the initial encounter and after continuous management of CRS for a mean of 40 months. The Sinonasal Outcome Test (SNOT-22) and Lund-MacKay scores were measured on initial visits, and SNOT-22 was repeated at the end of follow-up. Logistic regression was used to compare outcomes between the different groups adjusted for comorbidities and demographics. RESULTS: Among the 977 enrolled CRS cases, 615 (63.0%), 235 (24.1%) and 138 (13.0%) were White, AA and Latinx respectively. There was no difference in severity of CRS based on Lund-MacKay scores and SNOT-22 scores, and frequency of other comorbidities at presentation among the 3 groups. During the follow-up period, compared with Whites, AA and Latinx were less frequently evaluated by an allergist. AAs had less frequent CRS related visits and lower final SNOT-22 score compared with Whites. CONCLUSION: Although our enrolled patients from the 3 ethnic groups had similar clinical characteristics and disease burden at baseline, AAs had less frequent follow-up visits and worse final SNOT-22 after 40 months of follow-up. The observed poorer outcomes in AAs are likely owing to inequity in healthcare access evidenced by differences in insurance and suboptimal management of CRS.

Temporal patterns of nasal symptoms in patients with mild severity SARS-CoV-2 infection.

BACKGROUND: No study to date has analyzed the progression of sinonasal symptoms over time in COVID-19 patients. The purpose of this study is to analyze the progression of sinonasal symptoms and risk factors for olfactory dysfunction in the mild severity COVID-19 patient. METHODS: An internet survey was used to assess sinonasal symptoms in patients with COVID-19. Changes in rhinologic domain and symptom-specific Sinonasal Outcome Test (SNOT-22) scores were compared at five time points: two weeks before diagnosis, at diagnosis, two weeks after diagnosis, four weeks after diagnosis, and six months after diagnosis. RESULTS: 521 responses were collected. Rhinologic domain SNOT-22 scores increased significantly (p < 0.001) to 8.94 at the time of diagnosis, remained elevated two weeks post-diagnosis (5.14, p = 0.004), and decreased significantly four weeks post-diagnosis (3.14, p = 0.004). Smell-specific SNOT-22 scores peaked at the time of diagnosis (2.05, p < 0.001), remained elevated two weeks after diagnosis (1.19, p < 0.001), and returned to baseline four weeks post-diagnosis (0.64, p > 0.999). Taste-specific SNOT-22 scores also peaked at diagnosis (2.06, p < 0.001), remained elevated two weeks after diagnosis (1.19, p < 0.001), and returned to baseline four weeks after diagnosis (0.71, p > 0.999). There were no significant differences in sense of smell or taste between 1-month and 6-month timepoints. CONCLUSION: Sinonasal symptoms, particularly loss of smell and taste, may be important presenting symptoms in the mild severity COVID-19 patient. Our findings support incorporating these symptoms into screening protocols. LEVEL OF EVIDENCE: 4.

Prior smoking and nasoseptal flap usage adversely impact quality of life and healing after endoscopic pituitary surgery.

OBJECTIVE: Endoscopic pituitary surgery (EPS) via the endonasal transsphenoidal approach is well established as an effective treatment modality for sellar masses. The objective of this study was to determine the relationship between key patient and operative variables and rhinological outcomes as determined by the 22-item Sino-Nasal Outcome Test (SNOT-22) and endoscopic scores following EPS. METHODS: Prospectively collected SNOT-22 scores and objective endoscopic data were analyzed from a cohort of 109 patients who underwent EPS and had at least 90 days of postoperative follow-up. Trends in postoperative SNOT-22 scores were analyzed using linear mixed-effects models. Time to return to baseline endoscopic score was analyzed using Cox regression. RESULTS: After adjusting for age and sex, the authors found that prior smokers had higher total and rhinological subdomain SNOT-22 scores (p < 0.01, 95% CI 5.82-16.39; p = 0.01, 95% CI 1.38-5.09, respectively) following EPS. Nasoseptal flap use also showed higher total and rhinological subdomain SNOT-22 scores (p = 0.01, 95% CI 1.62-12.60; p = 0.02, 95% CI 0.42-4.30, respectively). Prior sinonasal surgery and concurrent septoplasty did not affect the change in SNOT-22 total scores over time (p = 0.08, 95% CI -0.40 to 0.02; p = 0.33, 95% CI -0.09 to 0.29). CONCLUSIONS: The findings suggest that the evolution of healing and patient-reported quality of life (QOL) measures are multifaceted with contributions from two key variables. Nasoseptal flap usage and prior smoking status may adversely impact postoperative QOL. No variables were found to be associated with objective postoperative endoscopic findings.

Assessment of post-operative healing following endoscopic, transnasal, transsphenoidal pituitary surgery without formal sellar grafting.

INTRODUCTION: Multiple options exist for sellar reconstruction after endoscopic transnasal, transsphenoidal surgery (TSS) including free mucosa, fat, bone and synthetic materials. The objective of this study was to assess healing and mucosalization of the sellar face following TSS without formal sellar grafting or reconstruction. METHODS: Single institution retrospective chart review was conducted for patients undergoing TSS without intraoperative CSF leaks between January 2014 and March 2017 at Rush University Medical Center. No formal sellar reconstruction was performed for the entire patient group. Follow-up endoscopic data and clinical notes were coded for time to mucosalization of the sella as well as degree of abnormal mucosal healing, epistaxis, crusting and scarring. RESULTS: 83 patients were included in this study. Mean time to mucosalization was 119 days (range, 17 to 402 days). Incidence of abnormal mucosal healing, epistaxis, crusting and scarring increased from the first to the second postoperative visit but trended down by the third visit. Nasal crusting was the most common finding, followed by abnormal mucosal healing. Chi square analysis showed smoking to be associated with prolonged time to full mucosalization of the sella. Two patients (2.4%) had post-operative CSF leaks requiring lumbar drain placement. CONCLUSION: Adequate sellar healing is achievable in all cases without formal grafting or reconstruction after TSS. Great care must be exercised given the small inherent risk of unmasking a subclinical intraoperative CSF leak. Patients should be followed closely endoscopically during the first four months after TSS to minimize the impact of crusting.

Rapid implementation of COVID-19 tracheostomy simulation training to increase surgeon safety and confidence.

OBJECTIVE: To determine if rapid implementation of simulation training for anticipated COVID-19 tracheostomy procedures can increase physician confidence regarding procedure competency and use of enhanced personal protective equipment (PPE). METHODS: A brief simulation training exercise was designed in conjunction with the development of a COVID-19 Tracheostomy Protocol. The simulation training focused primarily on provider safety, pre and post-surgical steps and the proper use of enhanced PPE. Simulation training was performed in the simulation lab at the institution over 2 days. Pre and post self-evaluations were measured using standardized clinical competency questionnaires on a 5-point Likert Scale ranging from "No knowledge, unable to perform" up to "Highly knowledgeable and confident, independent." RESULTS: Physicians self-reported a significant increase in knowledge and competency immediately after completing the training exercise. Resident physicians increased from a mean score of 3.00 to 4.67, p-value 0.0041, mean increase 1.67 (CI 95% 0.81 to 2.52). Attending physicians increased from a mean score of 2.89 to 4.67, p-value 0.0002, mean increase 1.78 (CI 95% 1.14 to 2.42). Overall, all participants increased from a mean score of 3.06 to 4.71, p-value 0.0001, mean increase 1.65 (CI 95% 1.24 to 2.05). DISCUSSION: Implementation of this simulation training at our institution resulted in a significant increase in physician confidence regarding the safe performance of tracheostomy surgery in COVID-19 patients. IMPLICATIONS FOR PRACTICE: Adoption of standardized COVID-19 tracheostomy simulation training at centers treating COVID-19 patients may result in improved physician safety and enhanced confidence in anticipation of performing these procedures in real-life scenarios.

Risk of obstructive sleep apnea in African American patients with chronic rhinosinusitis.

BACKGROUND: It is widely known that patients with chronic rhinosinusitis (CRS) commonly experience sleep disruption. Many of these patients have the associated diagnosis of obstructive sleep apnea (OSA). However, little is known about the risk factors for developing OSA in the CRS population. OBJECTIVE: To identify the risk factors for OSA in CRS to determine who should be screened for OSA among patients with CRS. METHODS: We evaluated a large cohort of patients with confirmed diagnostic criteria for CRS. Patient medical records were reviewed to identify those with OSA confirmed by overnight polysomnography. Records were further reviewed for demographic information (age, sex, race, and ethnicity), body mass index, and medical history, including the presence of nasal polyps, asthma, aspirin-exacerbated respiratory disease, allergic rhinitis, and eczema. The number of endoscopic sinus operations, duration of CRS, presence of subjective smell loss, and computed tomography Lund-Mackay score were also ascertained. RESULTS: A total of 916 patients with CRS were included in the study. Implementation of a multivariable regression model for identifying adjusted risk factors revealed that African American patients had a significantly higher risk for OSA than white patients, with an adjusted odds ratio of 1.98 (95% confidence interval, 1.19-3.29). Furthermore, patients with CRS without nasal polyps were at higher risk for OSA, with an odds ratio of 1.63 (95% confidence interval, 1.02-2.61) compared with patients with CRS with nasal polyps. CONCLUSION: African American patients with CRS were at higher risk for OSA compared with white patients, and this patient group needs to be screened for OSA.

Prevalence of allergic rhinitis and asthma in patients with chronic rhinosinusitis and gastroesophageal reflux disease.

BACKGROUND: An association between chronic rhinosinusitis (CRS) and gastroesophageal reflux disease (GERD) has been previously reported; however, the underlying factors linking CRS and GERD remain to be elucidated. OBJECTIVE: To assess the association of GERD and CRS using prospective and retrospective approaches. METHODS: The retrospective study comprised a large cohort of CRS cases, whereas the prospective arm evaluated a series of CRS cases and controls. RESULTS: In the retrospective arm of the study, of the 1066 patients with CRS, 112 (10.5%) had GERD. Among patients with CRS, GERD was associated with higher body mass index, older age, and female sex. The odds ratios (ORs) for asthma and allergic rhinitis in the CRS group with GERD compared with the CRS group without GERD were 2.89 (95% confidence interval [CI], 1.905-4.389) and 2.021 (95% CI, 1.035-3.947). Furthermore, GERD was associated with a greater duration of CRS. Ninety patients with CRS and 81 controls were enrolled in the prospective arm of the study. In the CRS group, GERD was associated with asthma (OR, 4.77; 95% CI, 1.27-18.01). Patients with CRS and GERD had a longer duration and a younger age at onset of CRS. In controls, no association was found between GERD and asthma (OR, 0.67; 95% CI, 0.09-5.19) or allergic rhinitis (OR, 0.35; 95% CI, 0.05-2.59). CONCLUSION: Patients with CRS and GERD are more likely to have atopic conditions and asthma when compared with patients with CRS but without GERD. One of the potential explanations of this link is that comorbid GERD and atopic disease are potential risk factors for development of CRS.

Endoscopically-derived bacterial cultures in chronic rhinosinusitis: A systematic review.

BACKGROUND: Culture-directed antibiotic therapy represents an important component in the management paradigm of chronic rhinosinusitis (CRS). The objective of this study was to systematically review the literature to assess culture yield of the most common aerobic and anaerobic pathogens. METHODS: A total of 43 studies between 1975 and 2010 were included. RESULTS: The composite data comprised 3528 patients with 6005 total culture specimens. The cultures were obtained in operating room in 33 (76.7%) and clinic in 10 (23.3%) of the studies, respectively. The most common site of culture was the maxillary sinus in 18 (41.9%) of the studies. The most common assay techniques reported were swab in 19 (44.2%) and aspirate in 12 (27.9%) studies. The most common gram positive aerobes reported were coagulase negative Staphylococcus and Staphylococcus aureus in 630 (34.7%) and 481 (26.5%) of the cultures, respectively. The most common gram negative aerobes included Haemophilus influenzae and Pseudomonas aeruginosa in 245 (27.0%) and 198 (21.6%) cultures, respectively. The most common anaerobes reported were Peptostreptococcus species in 156 (19.6%) and Bacteroides species in 153 (19.2%) cultures. CONCLUSION: This study provides a composite snapshot of the literature accrued on the microbiology of CRS. It should serve to apprise clinicians on the most common aerobic and anaerobic organisms in CRS patients when employing culture-directed antimicrobial therapy.

Endoscopic culture-directed antibiotic therapy: Impact on patient symptoms in chronic rhinosinusitis.

BACKGROUND: Endoscopically guided cultures are frequently employed to guide antimicrobial therapy in refractory chronic rhinosinusitis (CRS) patients. The objective of this study was to determine the impact of culture-directed antibiotics on patient symptoms. METHODS: Retrospective review was conducted of 105 adult CRS patients undergoing evaluation in the ambulatory clinic of tertiary care academic medical center. RESULTS: The most common microbes were Staphylococcus aureus (29.5%), Pseudomonas aeruginosa (23.8%) and methicillin-resistant S. aureus (11.4%). Normal respiratory flora or no growth was found in 19% of patients. Culture results changed antibiotic choices in 77% of patients. Statistically significant change in total SNOT-20 scores and all 4 subdomains was noted, with improvement being clinically meaningful in the rhinologic subdomain (-1.10, p<0.0001). Repeat purulence was only noted in 5 cases (4.8%). Multivariate regression analysis demonstrated that concurrent use of oral steroids was independently associated with improvement in the rhinologic subdomain (p=0.0041). The mean length of follow-up was 37 days. Length of follow-up (14-30, 31-60, 61-90 days) did not statistically impact SNOT-20 scores. CONCLUSION: Endoscopic-derived sinus cultures are associated with clinically meaningful change in the rhinologic subdomain of SNOT-20 scores, and repeat purulence was infrequently noted at follow-up. Further prospective studies are needed to better delineate the role of cultures in CRS management. LEVEL OF EVIDENCE: 4.

Ectopic Olfactory Neuroblastoma: Systematic Review of a Rare Clinical Entity among Sinonasal Tumors.

Objectives Ectopic olfactory neuroblastoma is an uncommon manifestation of an already rare neoplasm. We aimed to systematically review the literature for cases of ectopic olfactory neuroblastoma to better characterize this rare disease entity and to present two new case reports. Methods A search of the PubMed and Embase databases was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify English-language articles reporting cases of ectopic olfactory neuroblastoma, published from 1955 through November 2021. Results Sixty-six cases of ectopic olfactory neuroblastoma were identified in 62 articles including the current review. Ectopic olfactory neuroblastoma arose in a wide age range (2-89 years) without significant sex predilection. It occurred most commonly in the ethmoid (25%), maxillary (25%), and sphenoid (16%) sinuses. Seventy-three percent of cases presented with low Hyams grade (I and II). The most common symptoms were nasal obstruction (32%) and epistaxis (32%). Paraneoplastic syndromes were observed in 27% of patients. The most common treatment was surgical resection followed by adjuvant radiotherapy. Overall, 76% of all patients were disease-free at the time of last follow-up. Locoregional recurrences and distant metastases were found in 19 and 5% of cases, respectively. Conclusion This systematic review describes previously reported cases of ectopic olfactory neuroblastoma, a disease entity with poorly understood characteristics. Physicians should consider olfactory neuroblastoma in the differential diagnosis for sinonasal masses, as their ectopic presentation may present considerable diagnostic and therapeutic difficulties. Patients with olfactory neuroblastoma may benefit from long-term follow-up and routine endoscopic examinations for surveillance of ectopic recurrences.

Computed Tomography Imaging Patterns of Sinonasal Inverted Papillomas: Comparison of Primary and Recurrent Disease.

OBJECTIVE: To analyze clinical and radiographic features that may impact the rate of focal hyperostosis (FH) on computed tomography (CT) for primary and recurrent sinonasal inverted papillomas (IPs) as well as highlight factors that may affect concordance between FH and IP true attachment point (TAP). METHODS: All IPs resected between 2006 and 2022 were retrospectively reviewed. CTs were read by a neuroradiologist blinded to operative details. IP with malignancy was excluded. Operative reports and long-term follow-up data were evaluated. RESULTS: Of 92 IPs, 60.1% had FH, 25% had no CT bony changes, and 20.7% were revision cases. The recurrence rate for rhinologists was 10.5% overall and 7.3% for primary IPs. Primary and revision IPs had a similar rate of FH (63% vs. 52.6%; p = 0.646) and FH-TAP agreement (71.7% vs. 90%; p = 0.664). Nasal cavity IPs, especially with septal attachment, were more likely to lack bony changes on CT (57.1%) compared to other subsites (p = 0.018). Recurrent tumors were 16 mm larger on average (55 mm vs. 39 mm; p = 0.008). FH (75.0% vs. 60.9%; p = 0.295), FH-TAP concordance (91.7% vs. 74.4%; p = 0.094), and secondary IP (18.8% vs. 20.3%; p = 0.889) rates were similar between recurrent and nonrecurrent tumors. CONCLUSION: Primary and revision IPs have a similar rate of FH and FH-TAP agreement. Nasal cavity IPs are less likely to exhibit bony CT changes. Lower recurrence was associated with smaller size and fellowship training but not multiple TAPs, revision, FH absence, or FH-TAP discordance. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:1591-1596, 2024.

The Use of Artificial Intelligence to Improve Readability of Otolaryngology Patient Education Materials.

OBJECTIVE: The recommended readability of health education materials is at the sixth-grade level. Artificial intelligence (AI) large language models such as the newly released ChatGPT4 might facilitate the conversion of patient-education materials at scale. We sought to ascertain whether online otolaryngology education materials meet recommended reading levels and whether ChatGPT4 could rewrite these materials to the sixth-grade level. We also wished to ensure that converted materials were accurate and retained sufficient content. METHODS: Seventy-one articles from patient educational materials published online by the American Academy of Otolaryngology-Head and Neck Surgery were selected. Articles were entered into ChatGPT4 with the prompt "translate this text to a sixth-grade reading level." Flesch Reading Ease Score (FRES) and Flesch-Kincaid Grade Level (FKGL) were determined for each article before and after AI conversion. Each article and conversion were reviewed for factual inaccuracies, and each conversion was reviewed for content retention. RESULTS: The 71 articles had an initial average FKGL of 11.03 and FRES of 46.79. After conversion by ChatGPT4, the average FKGL across all articles was 5.80 and FRES was 77.27. Converted materials provided enough detail for patient education with no factual errors. DISCUSSION: We found that ChatGPT4 improved the reading accessibility of otolaryngology online patient education materials to recommended levels quickly and effectively. IMPLICATIONS FOR PRACTICE: Physicians can determine whether their patient education materials exceed current recommended reading levels by using widely available measurement tools, and then apply AI dialogue platforms to modify materials to more accessible levels as needed. LEVEL OF EVIDENCE: Level 5.

Comparative Performance of ChatGPT 3.5 and GPT4 on Rhinology Standardized Board Examination Questions.

Objective: Advances in deep learning and artificial intelligence (AI) have led to the emergence of large language models (LLM) like ChatGPT from OpenAI. The study aimed to evaluate the performance of ChatGPT 3.5 and GPT4 on Otolaryngology (Rhinology) Standardized Board Examination questions in comparison to Otolaryngology residents. Methods: This study selected all 127 rhinology standardized questions from www.boardvitals.com, a commonly used study tool by otolaryngology residents preparing for board exams. Ninety-three text-based questions were administered to ChatGPT 3.5 and GPT4, and their answers were compared with the average results of the question bank (used primarily by otolaryngology residents). Thirty-four image-based questions were provided to GPT4 and underwent the same analysis. Based on the findings of an earlier study, a pass-fail cutoff was set at the 10th percentile. Results: On text-based questions, ChatGPT 3.5 answered correctly 45.2% of the time (8th percentile) (P = .0001), while GPT4 achieved 86.0% (66th percentile) (P = .001). GPT4 answered image-based questions correctly 64.7% of the time. Projections suggest that ChatGPT 3.5 might not pass the American Board of Otolaryngology Written Question Exam (ABOto WQE), whereas GPT4 stands a strong chance of passing. Discussion: The older LLM, ChatGPT 3.5, is unlikely to pass the ABOto WQE. However, the advanced GPT4 model exhibits a much higher likelihood of success. This rapid progression in AI indicates its potential future role in otolaryngology education. Implications for Practice: As AI technology rapidly advances, it may be that AI-assisted medical education, diagnosis, and treatment planning become commonplace in the medical and surgical landscape. Level of Evidence: Level 5.

Histopathology of Recalcitrant Maxillary Sinusitis Necessitating Endoscopic Medial Maxillectomy.

OBJECTIVES: Endoscopic medial maxillectomy (EMM) is an effective intervention for patients with recalcitrant maxillary sinusitis after previous middle meatal antrostomy. The pathophysiology of refractory maxillary sinusitis is incompletely understood. We aim to identify trends in structured histopathology (SHP) to better understand how tissue architecture changes contribute to refractory sinusitis and impaired mucociliary clearance. METHODS: All patients who underwent EMM or standard maxillary antrostomy for recalcitrant maxillary sinusitis of various forms were included. Retrospective chart review was conducted to collect information on demographics, disease characteristics, comorbid conditions, culture data, and SHP reports. Chi-squared and logistic regression analyses were performed for SHP variables. RESULTS: Forty-one patients who underwent EMM and 464 patients who underwent maxillary antrostomy were included. On average, the EMM cohort was 10 years older (60.9 years vs. 51.1 years; p = 0.001) and more often had a history of prior sinus procedures (73.2% vs. 40.9%; p < 0.001). EMM patients had higher rates of fibrosis (34.1% vs. 15.1%, p = 0.002), and this remained statistically significant when controlling for prior sinus procedures and nasal polyposis (p = 0.001). Cultures positive for pseudomonas aeruginosa (38.2% vs. 5.6%, p < 0.001) and coagulase negative staphylococcus (47.1% vs. 23.5%, p = 0.003) were more prevalent in the EMM group. CONCLUSION: Fibrosis and bacterial infections with Pseudomonas and coagulase negative Staphylococcus were more prevalent in patients requiring EMM. This may contribute to the multifactorial etiology of impaired mucociliary clearance in patients with recalcitrant maxillary sinusitis. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:2646-2652, 2024.