Otolaryngology Applicant Perspectives on In-person and Virtual Residency Interviews.

OBJECTIVE: The objective of this study was to understand applicant perspectives on in-person and virtual otolaryngology residency interviews. STUDY DESIGN: Survey study. SETTING: Otolaryngology residency applicants who were interviewed during 2022-2023. METHODS: Survey sent to all otolaryngology residency applicants who interviewed during the 2022-2023 interview season. RESULTS: A total of 499 applicants were surveyed with 150 responses (30%). Approximately 48.3% of respondents were offered an in-person interview with 78.9% accepting the offer. Of those who did not accept, reasons included not wanting to travel (21.1%) and time conflicts (15.5%). When comparing virtual versus in-person interviews, those who attended virtual interviews were more likely to disagree that they connected with residents (P = .02) and that they had an improved perspective of the program (P = .002). The majority of applicants agreed that virtual interviews are more inclusive and equitable than in-person interviews (70.4%). When asked which interview style applicants would prefer, 63.1% of applicants preferred an in-person interview when compared to virtual with a second look option (29.5%) and virtual (7.4%). Respondents who self-identified as being underrepresented in medicine were less likely to choose in-person as their preferred interview format (P = .01) and were more likely to decline an in-person interview offer due to monetary limitations (P = .04). CONCLUSIONS: Applicants indicated dissatisfaction with connecting with residents and improving their perspective of the program when in a virtual setting. Applicants felt that virtual interviews were more equitable, but that if the barriers to equity were lessened then they would prefer in-person interviews.

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

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

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

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

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

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

Secondary overtriage of isolated facial trauma.

DESIGN: Retrospective chart review. SETTING: Academic, tertiary care, level I trauma center in a rural state. BACKGROUND: Unnecessary transfer of certain facial trauma patients results in a burden of time, money, and other resources on both the patient and healthcare system; identification and development of outpatient treatment pathways for these patients is a significant opportunity for cost savings. OBJECTIVES: To investigate the treatment and disposition of un-complicated, stable, isolated facial trauma injuries transferred from outside hospitals and determine the significance of secondary overtriage. METHODS: Retrospective chart review utilizing our institutional trauma database, including patients transferred to our emergency department between January 2012 and December 2017. Patients were identified by ICD9 or ICD10 codes and only those with isolated facial trauma were included. RESULTS: We identified 538 isolated facial trauma patients who were transferred to our institution during the study period. The majority of those patients were transferred via ground ambulance for an average of 76 miles. Overall, 82% of patients (N = 440) were discharged directly from our institution's emergency department. Almost 30% of patients did not require any formal treatment for their injuries; the potential savings associated with elimination of these unnecessary transfers was estimated to be between $388,605 and $771,372. CONCLUSIONS: We identified a high rate of patients with stable, isolated facial trauma that could potentially be evaluated and treated without emergent transfer. The minimization of these unnecessary transfers represents a significant opportunity for cost and resource utilization savings. LEVEL OF EVIDENCE: 2b- Economic and Cost Analysis.

Feasibility of Implementing Opioid Stewardship Recommendations for Sinonasal Surgery.

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

Is weight a predictive risk factor of postoperative tonsillectomy bleed?

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

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

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

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

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

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

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

Strategies for decreasing contamination of homemade nasal saline irrigation solutions.

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

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

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

Current perioperative practice patterns for minimizing surgical site infection during rhinologic procedures.

BACKGROUND: There is a paucity of information in the literature regarding the best practices to reduce surgical site infections associated with rhinologic surgery. METHODS: We surveyed the American Rhinologic Society (ARS) membership to assess current perioperative infection control measures performed for rhinologic procedures, with the goal of establishing a baseline of current practice. RESULTS: Results revealed that for most rhinologic procedures performed in the operating room (OR) setting, the majority of physicians gown and drape in a sterile fashion and perform a complete surgical scrub of their hands and forearms but do not prep the facial skin with an antimicrobial agent. For rhinologic procedures performed in the office setting, the majority of physicians do not perform any of the aforementioned perioperative measures for any of the office procedures. Interestingly, for physicians that perform inferior turbinate reductions in both settings, 45% gown and drape in a sterile fashion and 28% perform a complete surgical scrub of their hands in the OR setting but not in the office setting. The most stringent measures were performed for endoscopic skull-base procedures, with over 90% of responders administering perioperative antibiotics, gowning and draping in a sterile fashion, and performing a complete surgical scrub of their hands. Despite lack of demonstrated benefit, antibiotics were used variably for the other procedures. CONCLUSION: This survey demonstrates that there is great variability in the perioperative measures rhinologists perform to reduce surgical site infection, which differs by the practice site. These data serve as a baseline for future studies.

Diagnostic criteria for a curable form of chronic rhinosinusitis: the mucous recirculation syndrome.

In clinical practice, nonallergic rhinosinusitis (rhinopathy) is a common diagnosis of exclusion. The mucous recirculation syndrome is one incompletely defined condition that masquerades as nonallergic rhinopathy. Mucous recirculation syndrome, a curable condition, should be differentiated from nonallergic rhinopathy. The underdiagnosis of this condition is due in part to a lack of diagnostic criteria. In this article, we review the medical literature to better characterize mucous recirculation syndrome and to establish diagnostic criteria for it.

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

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

Effective use of physician extenders in an outpatient otolaryngology setting.

Physician extenders may be a valuable asset to an outpatient otolaryngology practice. The adjunctive care provided by physician extenders appears to be cost effective and has the advantages of increasing patient education, promoting physician productivity, and improving management of chronic conditions. Practice types that may benefit from advanced practice providers include group or solo practices with high demand or who need improved efficiency. We discuss five different practice models for incorporation of advanced practice providers in an outpatient otolaryngology practice. These models include scribe, collaborative, limited independent, partial independent, and near complete independent practice and are based primarily on the autonomy level of the physician extender. In additon, we examine available literature discussing the cost effectiveness of physician extenders used in an outpatient setting.

Characteristics of nasal injuries incurred during sports activities: analysis of 91 patients.

Nasal injuries are among the most common sports injuries. We conducted a prospective, observational study of 91 patients, aged 7 to 60 years (mean: 18.3), who had sustained a nasal injury while engaging in a sport, exercise, or other recreational physical activity. We found that a substantial proportion of these injuries occurred in females (29.7% of cases). A high percentage of injuries (86.8%) occurred in those who had been participating in a noncontact sport; the sport most often implicated was basketball (26.4%). Also, injuries were more common during organized competition as opposed to recreational play (59.3 vs. 40.7%). Of the 91 nasal injuries, 59 (64.8%) were fractures, most of which were treated with a closed reduction. Almost all of the patients in this study (92.3%) were able to return to their sport. We conclude that most sports-related nasal fractures are not preventable.

Complications of allergic fungal sinusitis.

PURPOSE: Allergic fungal sinusitis is a syndrome of chronic noninvasive fungal sinusitis that results in the accumulation of eosinophil-rich allergic mucin within the paranasal sinuses. This mucin may become an expansile mass leading to complications that have not been well characterized or classified. METHODS: Inclusion criteria for this study required meeting previously published diagnostic criteria and complications greater than nasal polyps or sinusitis itself. Four patients from our cohort and 30 patients identified in a literature search formed the study group. RESULTS: The majority of patients had pre-existing asthma or allergic rhinitis, or both, and 37% had nasal polyps before presentation. However, 27% had no previous history of rhinosinusitis or nasal polyposis. Complications of allergic fungal sinusitis fell into discrete categories: ophthalmic (n=13), sinobronchial allergic mycosis (n=9), bony erosion (n=8), cavernous venous thrombosis (n=3), and otic involvement (n=1). CONCLUSION: Visual symptoms, proptosis, headaches, and increased nasal symptoms, especially in association with bony erosions on sinus computed tomography, suggest allergic fungal sinusitis and its complications in patients with chronic rhinosinusitis and nasal polyps. Patients with allergic fungal sinusitis may present with a complication of the disease as the first symptom. Complications may be categorized into groups that facilitate surveillance and early identification.