Adaptation and Validation of the Hebrew Version of the Nasal Obstruction Symptom Evaluation (NOSE) Scale.

BACKGROUND: Nasal obstruction is one of the most common complaints in the practice of rhinology. OBJECTIVES: To adapt the Nasal Obstruction Scale Evaluation (NOSE) questionnaire to Hebrew (H-NOSE) and to assess its sensitivity and specificity. METHODS: Candidates for surgical intervention due to isolated nasal obstruction and healthy volunteers (controls) were included in the validation. The English NOSE questionnaire was translated into Hebrew and re-translated for translation validity. Patients completed the H-NOSE questionnaire before and after surgery for nasal obstruction. The same questionnaire was completed by the controls. Test-retest reliability was performed within 2 weeks. Psychometric properties (reliability, reproducibility, validity, and responsiveness) were assessed by a test-retest procedure, internal consistency, correlation to the Hebrew Sino-Nasal Outcome Tool 22 (He-SNOT-22), and response sensitivity. RESULTS: In total, 179 patients with nasal obstruction and 74 controls completed the questionnaire. Cronbach's alpha score was 0.93 for internal consistency. The receiver operating characteristic curve demonstrated high sensitivity and specificity (< 90%) and area under the curve was 0.97. We found no significant difference in test-retest reliability. The difference between the pre- and postoperative questionnaire scores was highly significant (13.9 ± 4.0 vs. 3.2 ± 4.1, respectively, P < 0.001). CONCLUSIONS: The H-NOSE questionnaire demonstrated reliable internal consistency, sensitivity, specificity, and reliability. The Hebrew version differentiated between patients and heathy controls and was easy to administer. This instrument is useful for Hebrew speaking patients who undergo surgery for nasal obstruction.

Quality of life after radio frequency ablation turbinate reduction (RFATR) among patients with rhinitis medicamentosa & withdrawal from decongestant topical spray abuse.

OBJECTIVE: Radiofrequency ablation (RFA) reliefs nasal obstruction and improves quality of life (QoL) in patients suffering from inferior turbinate hypertrophy (ITH). A substantial benefit was noted among patients suffering from Rhinitis Medicamentosa (RM), enabling ending decongestant spray abuse. Our aim was to establish the benefit from RFA with respect to QoL in patients suffering from ITH, due to the presence of RM. STUDY DESIGN: Prospective cohort study. METHODS: Prospective Cohort study, including patients suffering from ITH undergoing RFA between 9.2017 and 9.2019 in Tel Aviv Medical Center. The cohort was divided to RM and non-RM (including allergic, non-allergic) patients. The differences between the groups were compared before and after RFA, and included patients' complaints, clinical findings and QoL questionnaires (SNOT-22 & NOSE). In the RM group, the ability to wean from decongestants was also described. RESULTS: Our data demonstrated subjective QoL improvement following RFA (88.9 %, N = 90). All RM patients withdrawaled from nasal decongestant spray. NOSE questionnaire demonstrated a significant improvement in QoL after RFA in the RM group (PV = 0.025). SNOT-22 did not demonstrate significant difference in QoL between RM and the reference group (PV = 0.1). Rates of MCID>8.3 were high, without significant difference between the groups (PV = 0.2). CONCLUSION: RFA demonstrated effectiveness in achieving of withdrawal from decongestant spray in RM patients and may be a possible definitive treatment option for this group. The nasal obstruction component in SNOT-22 questionnaire & NOSE questionnaire showed improved QoL in comparison to controls. High QoL after RFA was established in our entire cohort.

Transorbital endoscopic-assisted management of intraorbital lesions: Experience of 11 cases.

PURPOSE: To present our experience in the management of selected extraconal orbital roof lesions utilizing the transorbital endoscopic approach. METHODS: A retrospective case series of patients who underwent transorbital endoscopic orbital surgery in a single medical center between 2015 to 2020. RESULTS: Eleven patients underwent transorbital endoscope assisted surgery for various indications. The mean age at surgery was 31.9 years (range, 6-73 years). Mean follow-up time was 18 months (range, 1-30). The aim of surgery was curative in 10 cases and diagnostic in one patient. Adequate specimen for tissue diagnosis was obtained from all patients. In 8 patients the procedure was completed through a superior eyelid crease incision, and in three patients a combined approach including functional endoscopic sinus surgery was used for achieving complete excision. None of the patients required conversion to an external wider orbital procedure. Intraoperative complication included cerebrospinal fluid leak in one case, which was addressed immediately; and postoperative complications included one case of pre-septal orbital cellulitis treated by intravenous antibiotics with complete resolution. CONCLUSION: Endoscopic-assisted transorbital approach enabled safe removal of selected lesions involving the orbital roof and provides an effective and less invasive alternative to a traditional frontal craniotomy or lateral orbitotomy.

The effect of septal deviation on postoperative quality of life in patients undergoing radiofrequency-assisted turbinate reduction.

Objectives: Inferior turbinate hypertrophy (ITH) and nasal septum deviation are leading causes of chronic nasal obstruction. Radiofrequency ablation (RFA) of hypertrophic inferior turbinates is effective for improving quality of life (QOL). We aim to assess QOL among patients with nasal obstruction associated with ITH and major deviated nasal septum. Methods: A prospective cohort study comparing the difference in improved QOL among patients with and without septal deviation following RFA treatment between March 2016 and June 2019. The patients formed two groups according to their grade of septal deviation. Patients participating filled in QOL questionnaires (Sino-Nasal Outcome Test-22 [SNOT-22] and Nasal Obstruction Symptom Evaluation [NOSE]) Pre- and 2 months postprocedure. Results: All patients demonstrated QOL improvement with no significant difference between those with and those without any degree of deviated septum, as demonstrated by their responses to the SNOT-22 questionnaire (p = .29), the NOSE questionnaire (p = .93), and the degree of nasal obstruction (question 22 in the SNOT-22 questionnaire) (p = .14). Conclusion: We conclude that septal deviation to certain degree does not preclude treatment of ITH with RFA nor does it negatively affect subjective improvement of the patient's QOL. Both those with and those without septal deviation will benefit similarly with regards to subjective QOL improvement.

Lacrimal sac diverticulum: clinical presentation and endoscopic management.

BACKGROUND: To describe the clinical presentation, surgical intervention and clinical outcomes of patients with a lacrimal sac diverticulum. METHODS: Retrospective chart review of all patients who underwent endonasal endoscopic dacryocystorhinostomy (DCR) in a single medical center from January 2010 to October 2020. The diagnosis of a lacrimal sac diverticulum was based upon intraoperative findings. RESULTS: In total, 406 patients underwent endonasal endoscopic DCR during the study period. Eight female patients (mean age 35 years) were diagnosed with a lacrimal diverticulum and underwent DCR by an endonasal endoscopic approach. The mean follow-up period was 11.5 months. All eight patients had cystic findings at the lacrimal fossa on imaging studies prior to surgery. Five patients had a history of dacryocystitis. The main presenting symptoms were epiphora and/or medial canthal swelling. The diverticulum was identified on the inferior wall in seven cases. A dacryolith in the lacrimal sac was identified intraoperatively in two patients. All patients showed full resolution of symptoms after surgery. There were no intraoperative or postoperative complications. CONCLUSION: Lacrimal sac diverticulum is a rare entity with female predominance. It may be the underlying etiology of epiphora and/or dacryocystitis. The diagnosis is based upon identifying the presence of a diverticulum intraoperatively. Endoscopic DCR is an effective approach for integrating both the lacrimal sac and diverticulum cavities into a single space, leading to resolution of symptoms.

Skull Base Reconstruction with Multilayered Fascia Lata: A Single-Center 17 Years Experience.

Objective Reconstruction after open surgery of anterior skull base lesions is challenging. The fascia lata graft is our workhorse for achieving dural sealing and preventing cerebrospinal fluid leak and meningitis. This study seeks to analyze the donor and recipient site complication rates after fascia lata reconstruction. Methods This is a retrospective review of all open anterior skull base operations in which a double-layer fascia lata graft was used for the reconstruction of the defect from 2000 to 2016 at the Tel-Aviv Sourasky Medical Center, a tertiary referral center in Israel. Results Of the 369 patients operated for skull base lesions, 119 underwent open anterior skull base surgery and were reconstructed with a fascia lata graft. The patients' mean age was 47.1 years, and 68 (57.1%) were males. The overall postoperative early and late donor site complication rates were 6.7% ( n = 8) and 5.9% ( n = 7), respectively. Multivariate analysis found minor comorbidities and persistent/recurrent disease as being predictors for early-term complications. The overall postoperative early central nervous system (CNS) complication rate was 21.8% ( n = 26), while 12.6% ( n = 15) of the patients had late postoperative CNS complications. Conclusion Reconstruction of open anterior skull base lesions with fascia lata grafting is a safe procedure with acceptable complication and donor site morbidity rates.

Outcomes of Tracheal Resections in Well-Differentiated Thyroid Cancer-A case series and meta-analysis.

BACKGROUND: Tracheal invasion in thyroid cancer is a well-known form of advanced disease. There is an ongoing controversy over outcomes of tracheal shaving in this situation. The aim of this study was to compare the results of tracheal shaving to radical resections in patients with low-volume tracheal involvement. METHODS: An institutional case series and a meta-analysis was conducted. All studies that included patients diagnosed with well-differentiated thyroid cancer (WDTC) and tracheal invasion were analyzed. Patients with low-volume tracheal invasion (according to the Shin classification) were extracted from the various studies and subsequently included in this study. The outcomes of tracheal shaving and radical resection were consolidated and compared. All recurrences and mortality over 10 years of follow-up were calculated using the Kaplan-Meier method. RESULTS: Institutional case series included 22 patients diagnosed with WDTC and tracheal invasion that underwent resection. There was one case of recurrence (4.5%) during the follow-up period and no mortality. The meta-analysis yielded a total of 284 patients from six studies who met the inclusion criteria. The 10-year overall survival was 82.4% for the shave group and 80.8% for the resection group. The combined Kaplan-Meier curves revealed no statistically significant difference between the two techniques (hazard ratio [HR] = 0.86, P = .768). The combined 10-year local control rate of the shave group was 90.2%. CONCLUSIONS: The outcomes of tracheal shaving in low-volume invasion are similar to more aggressive forms of tracheal resections. Shave resection is oncologically safe in carefully selected WDTC patients demonstrating minimal tracheal invasion.

The Role of Imaging in the Preoperative Assessment of Patients with Nasal Obstruction and Septal Deviation-A Retrospective Cohort Study.

Introduction Isolated nasal obstruction (INO) is a common complaint of multiple etiology. The preoperative evaluation of patients presenting with nasal obstruction and deviated nasal septum (DNS) does not typically include imaging. The benefits of performing computed tomography (CT) in the preoperative setting are inconclusive. Objective Assessing the contribution of preoperative CT to the surgical treatment of non-sinusitis patients presenting with INO and DNS. Methods A retrospective cohort study on patients referred to surgery for nasal obstruction due to DNS or turbinate hypertrophy between 2006 and 2015. Data was retrieved from patients' medical charts. The CT scans and clinical data were reassessed by a second surgeon blinded to the patients' clinical course. Results Seventy of the 843 patients (8.06%) who underwent endoscopic sinonasal procedures during the study period had presented with INO and met the inclusion criteria. Thirty-eight (55.88%) of them underwent CT scans during their preoperative assessment. Modification of the initial preoperative planning based on the radiological findings was required in 32 cases (84.2%). When reassessed by a second blinded surgeon, 58% of cases required surgical modification rather than classical submucosal resection of nasal septum and turbinate reduction ( P = 0.048). Conclusion Computed tomography was found beneficial in the preoperative planning for patients with INO. The original surgical plan based upon physical examination findings was modified based on radiological findings in 84.2% of the patients.

The Role of Imaging in the Preoperative Assessment of Patients with Nasal Obstruction and Septal Deviation-A Retrospective Cohort Study

Abstract Introduction Isolated nasal obstruction (INO) is a common complaint of multiple etiology. The preoperative evaluation of patients presenting with nasal obstruction and deviated nasal septum (DNS) does not typically include imaging. The benefits of performing computed tomography (CT) in the preoperative setting are inconclusive. Objective Assessing the contribution of preoperative CT to the surgical treatment of non-sinusitis patients presenting with INO and DNS. Methods A retrospective cohort study on patients referred to surgery for nasal obstruction due to DNS or turbinate hypertrophy between 2006 and 2015. Data was retrieved from patients' medical charts. The CT scans and clinical data were reassessed by a second surgeon blinded to the patients' clinical course. Results Seventy of the 843 patients (8.06%) who underwent endoscopic sinonasal procedures during the study period had presented with INO and met the inclusion criteria. Thirty-eight (55.88%) of them underwent CT scans during their preoperative assessment. Modification of the initial preoperative planning based on the radiological findings was required in 32 cases (84.2%). When reassessed by a second blinded surgeon, 58% of cases required surgical modification rather than classical submucosal resection of nasal septum and turbinate reduction (P = 0.048). Conclusion Computed tomography was found beneficial in the preoperative planning for patients with INO. The original surgical plan based upon physical examination findings was modified based on radiological findings in 84.2% of the patients.

Does Sinusitis Affect Lateralization of a Tuning Fork Weber Test?

OBJECTIVE: To describe the effect of sinusitis on Weber test lateralization which normally lateralizes toward the ear of a conductive hearing loss and away from the ear of a sensorineural hearing loss; to investigate whether the presence of an extra-aural condition might affect Weber test results. STUDY DESIGN: Descriptive study. SETTING: Tertiary referral center. SUBJECTS AND METHODS: Consecutive adult patients with maxillary and/or frontal sinusitis were included (study group), as well as patients with normal sinus structure and function (control group) were enrolled between February and September 2019. Presence or absence of paranasal disease and middle ear aeration was confirmed by computerized tomography. Subjects with otologic condition were excluded. The physical examinations, tympanograms, and audiograms were unremarkable. The Weber test consisted of 512, 1024, and 2048 Hz tuning forks that were applied on the central incisors and frontal midline, and lateralization patterns were compared with the extent of paranasal pathology. RESULTS: There were 44 participants (M:F=26:18), age 19 to 63 years (average 51). The cohort included 39 patients with sinusitis, affecting the frontal and/or maxillary sinus(es), as well as 5 controls without evidence of paranasal disease. There was a match between the extent of paranasal disease and the results of all 3 Weber test frequencies in 35 patients (80%). Omission of the 2048 and 1024 Hz tuning forks from the analysis yielded a match in 40 (91%) and 43 (98%) patients, respectively. No Weber test lateralized to the nondiseased sinus in any subject. Weber test lateralization was observed in 11% of patients, after the sinonasal pathology was successfully addressed. CONCLUSION: Weber test lateralization in the absence of aural pathology may be explained by asymmetry related to paranasal disease and may alert to its presence.

Endoscopic transsphenoidal surgery reduces the need for re-operation compared to the microscopic approach in pituitary macroadenomas.

INTRODUCTION: Pituitary surgery has shifted in recent years from microscopic surgery(MS) to endoscopic endonasal surgery (EES). However, the comparative long-term outcome of these surgical approaches, including the need for subsequent re-operation has never been reported. We present our experience in a high-volume referral center experienced in both endoscopic and microscopic approaches to compare the need for re-operation after initial resection of non-functioning pituitary macroadenomas using these surgical approaches. METHODS: 684 patients (398 with NF adenomas) underwent trans-sphenoidal pituitary surgery in our institution between 2006 and 2017. Complete follow-up (mean 72 months, minimum two years) was available in 87 newly diagnosed patients with non-functioning pituitary macroadenomas (NFPMA; 48-microscopic and 39-endoscopic). The EES approach has been used almost exclusively since 2012. The need for repeat operation for tumor resection during the follow-up period was assessed as the primary end-point of the study. Extracted data included various demographic and clinical parameters, radiographic findings as well as the extent of resection (EOR). RESULTS: The EOR was similar for both groups, with a trend towards better EOR in the EES group. The rate of surgical complications was also similar for both groups. There was a strong trend towards lower need for re-operation in the EES group compared to the MS group (12.8% vs. 29.2%, p = 0.056). In a multivariate analysis, only EOR and Knosp grade were independently associated with the need for re-operation surgery. CONCLUSION: Our data indicate that EES in NFPMA tends to be associated with a lower need for re-operation compared to the MS approach, with a similar rate of EOR and complications.

Averting Delayed Complications of Open Anterior Skull Base Surgery.

Objective Despite its technical feasibility, anterior skull base surgery still carries the risk of severe postoperative complications, morbidity, and mortality. The reported rate of complications has diminished over the past two decades, but they continue to pose various challenges. This study aims to report late complications in a relatively large series of patients who underwent open anterior skull base surgery, and to propose methods for averting such complications. Methods Retrospective chart review of all patients who underwent anterior open skull base surgery between 2000 and 2016 in a university-affiliated tertiary referral cancer center. Results There were 301 operations, of which 198 (65.8%) were for benign disease and 103 (34.2%) were for malignant tumors. The male-to-female ratio was 1.4:1, and the mean age was 44.8 years. Delayed complications occurred in 85 patients (28.2%): 31 (10.3%) involved wounds, 18 (13.9%) involved the central nervous system, and 14 (4.6%) involved the orbit. Multivariate analysis found malignant pathology, intracranial extension, and previous radiochemotherapy as predictors for the development of a delayed complication. The patients who were operated in the later study period (after 2007) had lower rates of all three types of complications compared with the earlier study period. Conclusion Delayed complications following skull base surgery are in decline. This is mainly due to the advancement in imaging studies, surgical techniques, development of sophisticated reconstructive procedures, and the cooperation of multidisciplinary teams. We attribute the reduction in our department to our revised treatment protocol which is presented herein, with emphasis on averting the occurrence of these complications. Level of Evidence The level of evidence is 4.

Prophylactic central neck dissection has no advantage in patients with metastatic papillary thyroid cancer to the lateral neck.

BACKGROUND: Papillary thyroid cancer (PTC) usually metastasizes via lymphatic channels in a sequential fashion, first to the central compartment, followed by the lateral neck. PTC patients diagnosed with lateral neck disease (N1b) without proof for central involvement traditionally undergo prophylactic central neck dissection (pCND). However, substantial evidence on outcomes to support this approach is lacking. MATERIALS AND METHODS: We conducted a dual center retrospective study to compare the rate of central neck recurrence between N1b PTC patients undergoing pCND and those spared pCND. All patients diagnosed with N1b PTC who underwent total thyroidectomy and lateral neck dissections with or without pCND between January 1998 and December 2015 were included in this study. The rates of central neck recurrences were compared between the groups. RESULTS: The 111 patients who met the inclusion criteria were 44 females (39.6%) and 67 males (60.4%), with a mean age of 50.2 ± 17.7 years, and a mean follow-up of 10.2 ± 5.3 years. Sixty patients (54.1%) underwent a pCND and 51 patients (45.9%) did not (non-pCND). During follow-up, 18 patients (16.2%) had level VI recurrences, 13 in the pCND group and 5 in the non-pCND group. Cox-regression models with propensity scoring did not reveal any inclination or an advantage for performing pCND. CONCLUSION: The present study demonstrated no advantage in performing pCND to prevent central neck recurrence among PTC patients with lateral neck involvement only. These findings question the need for pCND in patients without clinical evidence of central neck disease.

Rate of Occult Neck Nodal Metastasis in Parotid Cancer: A Meta-Analysis.

BACKGROUND: The risk for occult neck nodal metastasis in carcinoma of the parotid gland is inconclusive. Therefore, addressing a negative neck prophylactically and the extent to do so remain controversial. This systematic review aimed to determine the rate of occult nodal metastasis for each neck level, and consequently, to elucidate the proper extent of elective neck dissection (END). METHODS: A meta-analysis of all studies that included patients with a diagnosis of parotid malignancies who underwent an END was performed. The risk for occult nodal metastasis was calculated for each neck level separately. RESULTS: The search strategy identified 124 papers from January 1980 to December 2019 in the various databases. Nine retrospective studies (n =548) met the inclusion criteria. The risk for occult neck nodal metastasis ranged from 0.0 to 9.43% with a random-effect model of 2.2% for level 1 (n =459), from 3.4 to 28.38% with a random-effect model of 16.51% for level 2 (n =548), from 0.0 to 21.63% with a random-effect model of 4.23% for level 3 (n =518), from 0.0 to 17.02% with a fixed-effect model of 0.39% for level 4 (n =310), and from 0.0 to 11.63% with a fixed-effect model of 1.7% for level 5 (n =417). CONCLUSION: The rate of occult neck nodal metastasis in parotid malignancies is low, with neck level 2 the most commonly involved. The results of this meta-analysis prevented the authors from substantiating the appropriate extent of an END in parotid cancer.

Free flap transfers for head and neck and skull base reconstruction in children and adolescents - Early and late outcomes.

OBJECTIVES: Reconstruction of surgical defects by free tissue transfer following resection of head and neck tumors in children are sparse. This study aims to assess the feasibility and safety of free flap reconstruction following surgical ablation of head and neck and skull base tumors in children based on our experience and the recent literature. METHODS: Data from medical files of all children and adolescents <18 years of age who underwent free flap reconstruction following resection of head and neck and skull base tumors at our tertiary center between 2000 and 2018 were retrospectively reviewed. Data on early and late complications at the primary and donor sites, functional and aesthetic outcome, and tumor control were analyzed. RESULTS: Twenty-four children (mean age 11.3 ± 5.1 years) were enrolled. Early complications occurred in 14 (56%) and late complications occurred in 8 (32%) of the procedures, with surgical intervention required in 4 (16%). Prior chemoradiation, sarcoma, non-reanimation procedures, and the use of rectus abdominis free flaps were associated with higher complication rates. The final functional and cosmetic outcomes, including mastication, deglutition, and speech, were satisfactory in all patients with one exception. CONCLUSIONS: Free flap transfer is a safe and feasible technique for reconstructing head and neck and skull base defects following surgical excision of tumors in children. Early identification and precautionary measures against the effects of potential causes of complications may improve outcome. Larger international cohort studies are warranted.

Anterior Skull Base Surgery in the 21st Century: The Role of Open Approaches.

Treating malignant tumors of the anterior skull base (ASB) is a challenging task, given their late presentation, diverse histology, and involvement of an intricate anatomical space requiring complex surgery. Advances in imaging, gradual refinement of surgical and reconstruction techniques, and improvement of perioperative care during recent decades have resulted in improved clinical outcomes for patients. In addition, assessing functional outcomes and quality-of-life issues have become a fundamental part in the holistic care of patients with ASB tumors. Once dominated by open procedures, the modern field of skull base surgery is rapidly incorporating endoscopic techniques. These techniques have been previously reserved for sinonasal inflammatory diseases, but in recent years they have sequentially and increasingly been applied to more complex disorders. The list of indications includes intracranial pathologies and malignant sinonasal neoplasms with skull base involvement. Open ASB surgery in this new era is reserved for selected cases, yet it is still considered the "gold standard" for treating ASB malignancy. The paucity of evidence-based data regarding the management of ASB tumors is still a major limit of the discipline of ASB surgery, resulting from the rarity and high degree of heterogeneity of these tumors. Therefore, no guidelines exist and prospective large cohort collaborative studies are required in order to consolidate our knowledge of the behavior of each histology encountered, and to assess the clinical and quality-of-life outcomes of the different treatment modalities currently used.

Surgical management of odontogenic cysts involving the maxillary sinus- a retrospective study.

OBJECTIVE: To describe our strategy for the management of odontogenic cysts involving the maxillary sinus, and to define the role of transnasal endoscopic sinus surgery in the treatment algorithm. METHODS: A retrospective study was conducted. Included were all consecutive patients with odontogenic cysts involving the maxillary sinus who were treated in a single medical center between 2011 and 2019. Their medical records were reviewed for demographic data, preoperative presentation, surgical approach, final pathology, and postoperative course. Odontogenic cysts were classified as small or large according to maxillary sinus extension within or beyond the alveolar recess, respectively. RESULTS: A total of 30 patients with odontogenic cysts involving the maxillary sinus were treated by a team of maxillofacial and endoscopic sinus surgeons during the study period. There were 11 cases of dentigerous cysts, 11 radicular cysts, seven odontogenic keratocysts (OKCs), and one glandular cyst. Sixteen cases were managed by transnasal endoscopic sinus surgery alone and 14 were managed by a combined intraoral and endoscopic sinus surgery approach. A total of 22 patients had large cysts and total resection was achieved in 20 of them. There was one case of OKC recurrence during an average follow-up of 31 months. No major complications were recorded. CONCLUSIONS: The endoscopic approach can serve as an alternative to the transalveolar or lateral window approach. The endoscopic approach is associated with low morbidity and low recurrence rates.

Low rates of airway intervention in adult supraglottitis: A case series and meta-analysis.

PURPOSE: Acute supraglottitis (SG) can potentially lead to rapid airway obstruction. The last few decades have witnessed a shift towards a more conservative approach in airway management of adult SG. This study aims to evaluate this watchful approach based on a large case series combined with a high-level meta-analysis of all reports in the English literature. METHODS: Retrospective case series and meta-analysis. The medical records of all adult patients diagnosed as having SG who were hospitalized in a large-volume tertiary referral center between January 2007 and December 2018 were reviewed. A meta-analysis was conducted on all English literature published between 1990 and 2018. RESULTS: A total of 233 patients (median age 49.1 years, 132 males), were admitted due to acute SG during the study period. No airway intervention was required in 228 patients (97.9%). Five patients (2.1%) required preventive intubation, and two of them (0.9%) were later surgically converted to a tracheotomy. Patients who required airway intervention had higher rates of diabetes (P = .001), cardiovascular diseases (P = .036) and other comorbidities (P = .022). There was no mortality. The meta-analysis revealed that the overall intubation rates random effects model was 8.8% [95% confidence interval (CI) 4.6%-14.0%] and that the tracheotomy random effects model was 2.2% (95% CI; 0.5%-4.8%). The overall mortality rate was 0.89%. CONCLUSIONS: This study provides evidence of low rates of surgical airway intervention in patients diagnosed with SG worldwide. A conservative approach in adult SG is safe and should be advocated. LEVEL OF EVIDENCE: 2.

Anterior Median Skull Base Reconstruction Using a Vascularized Free Flap: Rationale, Patient Selection and Outcome.

Objectives To present our method of median anterior skull base (ASB) reconstruction using a subcranial approach with a free flap in cases of naso-fronto-orbital (NFO) bony segment failure and in patients at high risk for future failure of the bony frontal segment. Design This study presents as a retrospective case series. Setting Tertiary university-affiliated medical center. Participants Adult and pediatric patients who underwent median ASB resection via the subcranial approach with a free flap reconstruction were participated in this study. Main Outcome Measures Pathologic outcome and postoperative quality of life (QoL) as assessed by a validated Hebrew version of the "Anterior Skull Base Quality-of-Life Questionnaire." Results The departmental database yielded 13 suitable patients aged between 15 and 70 years. The main indication ( n = 7) for ASB surgery was osteoradionecrosis (ORN) of the NFO bony segment which was first detected at an average of 3.6 years (range: 2-32 years) postradiation therapy. High-risk patients for future ORN of the NFO segment ( n = 3) were primarily reconstructed using a vascularized free flap. Nine patients had malignant disease, and four of them were alive without evidence of disease during the follow-up period (average, 48 months). Their QoL was comparable to that of patients who had undergone subcranial ASB resection without free flap reconstruction. Conclusions The ASB median free flap method of reconstruction is a safe and reliable in cases of large complex median ASB defects without orbital resection or maxillectomy. This approach is suitable for patients who had undergone previous surgery, radiotherapy and/or those who present with osteoradionecrosis, as well as for patients with high risk of NFO segment ORN.

Endoscopic dacryocystorhinostomy: reasons for failure.

OBJECTIVE: Endoscopic dacryocystorhinostomy (DCR) is a widely performed and safe procedure for the treatment of nasolacrimal duct obstruction manifested as epiphora or dacryocystitis. Current success rates are above 90%. Data on causes for failure of the procedure are sparse. We investigated the influence of several preoperative parameters on surgery outcome and to establish that parameters are linked with failure. METHODS: A retrospective analysis of the medical records of all consecutive patients who underwent endoscopic DCR in the Tel-Aviv Medical Center, a tertiary referral center, between January 2010 and August 2016 were retrospectively examined and data on the occurrence of surgical failure and reasons for failure were retrieved. RESULTS: A total of 165 patients (183 eyes) were included. The overall success rate for the surgery was 94.7%. The parameters that correlated significantly with failure were coexisting diabetes mellitus (P = 0.037), allergy to medications (P = 0.034), and prior ocular surgery (P = 0.043). There was no correlation between the surgical failure rates and facial trauma, previous nasal or lacrimal surgery, or the usage of a stent. CONCLUSION: Endoscopic DCR is a safe and effective surgical procedure. Diabetes mellitus, allergies, and previous ocular surgery may lead to surgical failure. Patients with these risk factors should be aware of increased failure rates.