Anatomical variation of the posterior septal artery leads to refractory epistaxis.

Purpose: To report a rare variant of the posterior septal artery (PSA), which supplies blood to the posterior mucosa of the contralateral nasal septum. Case report: A 31-year-old female patient underwent suture removal 14 days after septoplasty and developed left-sided epistaxis 6 h after suture removal. To safely and effectively relieve the patient from epistaxis, the cauterization of the left PSA was performed under general anesthesia. However, 24 h after the first surgical hemostasis, the patient experienced epistaxis again in the right nasal cavity. We have reviewed the patient's sinus computed tomography again and found a rare variant of PSA, which is the right-sided PSA passing through a bony canal in the left-sided nasal septum. Discussion: The variant of PSA well explained the failure of the first hemostatic surgery. Therefore, we again performed a cauterization of the right-sided PSA, after which the patient recovered and no further epistaxis occurred. Conclusion: When cauterization of PSA is used to manage posterior epistaxis, it is necessary to pay attention to the possible variation in PSA.

Real-time augmentation of diagnostic nasal endoscopy video using AI-enabled edge computing.

KEY POINTS: AI-enabled augmentation of nasal endoscopy video images is feasible in the clinical setting. Edge computing hardware can interface with existing nasal endoscopy equipment. Real-time AI performance can achieve an acceptable balance of accuracy and efficiency.

Epidermoid Cyst at the Root of the Sphenoidal Pterygoid Process: A Rare Case Report.

Epidermoid cysts of the skull base are rare. We present the case of a woman with an epidermoid cyst at the root of the sphenoidal pterygoid process. She experienced tightness of the forehead skin without headache. Computed tomography (CT) scan revealed a hypodense lesion at the base of the skull in the right middle cranial fossa, which had partly eroded the pterygoid root. Magnetic resonance imaging (MRI) scan revealed a soft cystic mass that eroded the pterygoid root with hypo-/iso-intense on T1-weighted images, hyperintense on T2-weighted images, inhomogeneous hyperintense on diffusion-weighted images, a slightly low apparent diffusion coefficient, and no enhancement, suggesting a diagnosis of an epidermoid cyst. Surgical excision was performed using a nasal endoscope via the pterygoid process-root approach. A histopathological examination confirmed the diagnosis of an epidermoid cyst. At the 6-month follow-up, no recurrence was found on MRI or nasal endoscopy, and the symptoms of forehead tightness disappeared. In conclusion, epidermoid cysts at the root of the sphenoidal pterygoid process are exceptionally rare. Preoperative MRI and CT scans are necessary for the correct diagnosis and differentiation of other low-growing lesions. Nasal endoscopy is crucial for surgical excision and postoperative follow-up for potential recurrence.

Nasolacrimal duct rhinostomy for low-level nasolacrimal duct obstruction:long-term outcomes and surgical selection paradigm.

PROPOSE: This study aims to present long-term outcomes in a specific patient population experiencing epiphora due to low-level nasolacrimal duct obstruction (NLDO) following endonasal endoscopic nasolacrimal duct rhinostomy, and to propose a surgical selection paradigm for varying locations of NLDO. METHODS: Between September 1, 2017 and February 28, 2023, a retrospective analysis was conducted on 26 patients diagnosed with primary acquired nasolacrimal duct obstruction (PANDO) who underwent endonasal endoscopic nasolacrimal duct rhinostomy for low-level NLDO (defined as obstruction below the plane of the superior border of the inferior turbinate attachment). The study assessed surgical success through objective measures of anatomical patency and subjective measures of functional patency during a postoperative follow-up period of at least six months. Additionally, any complications that arose during this follow-up period were documented. RESULTS: The study included a cohort of 26 patients, consisting of 24 women and 2 men, with a mean age of 47.58 ± 3.09 years (range: 8-75). All patients underwent endoscopic nasolacrimal duct rhinostomy, with 10 eyes having previously undergone tear duct recanalization procedures. Anatomical patency was achieved in 88.5% (23/26) of cases, while functional patency was achieved in 80.8% (21/26) after an average follow-up period of 41.9 ± 22.1 months. No significant complications were observed in any of the patients during the follow-up period. CONCLUSION: Endonasal endoscopic nasolacrimal duct rhinostomy is effective in treating epiphora in over 80% of cases with low-level NLDO. Tailoring the surgery to the location of the obstruction can improve outcomes and minimize damage.

Features of Importance in Nasal Endoscopy: Deriving a Meaningful Framework.

OBJECTIVE: Critical components of the nasal endoscopic examination have not been definitively established for either the normal examination or for clinical disorders. This study aimed to identify concordance among rhinologists regarding the importance of examination findings for various nasal pathologies. STUDY DESIGN: A consortium of 19 expert rhinologists across the United States was asked to rank the importance of findings on nasal endoscopy for 5 different sinonasal symptom presentations. SETTING: An online questionnaire was distributed in July 2023. METHODS: The questionnaire utilized JotForm® software and featured 5 cases with a set of 4 identical questions per case, each covering a common indication for nasal endoscopy. Rankings were synthesized into Normalized Attention Scores (NASs) and Weighted Normalized Attention Scores (W-NASs) to represent the perceived importance of each feature, scaled from 0 to 1. RESULTS: General concordance was found for examination findings on nasal endoscopy within each case. The perceived features of importance differed between cases based on clinical presentation. For instance, in evaluating postnasal drip, the middle meatus was selected as the most important structure to examine (NAS, 0.73), with mucus selected as the most important abnormal finding (W-NAS, 0.66). The primary feature of interest for mucus was whether it was purulent or not (W-NAS, 0.67). Similar analyses were performed for features in each case. CONCLUSION: The implicit framework existing among rhinologists may help standardize examinations and improve diagnostic accuracy, augment the instruction of trainees, and inform the development of artificially intelligent algorithms to enhance clinical decision-making during nasal endoscopy.

Enhancing nasal endoscopy: Classification, detection, and segmentation of anatomic landmarks using a convolutional neural network.

KEY POINTS: A convolutional neural network (CNN)-based model can accurately localize and segment turbinates in images obtained during nasal endoscopy (NE). This model represents a starting point for algorithms that comprehensively interpret NE findings.

Nasal endoscopy: What have we been missing?

Despite the widespread adoption of nasal endoscopy (NE) in the evaluation of sinonasal disease, its diagnostic potential may still be underutilized. Developments in endoscopic technology have led to significant improvements in video quality and maneuverability. However, there is concern that NE continues to be used primarily for the identification of gross pathology, with relative neglect of more subtle findings such as surface features of inflammation and mucus. With fewer technical limitations to perceive these abnormalities, there is potential to greatly improve the diagnostic value of NE. The reader is herein asked to consider several important visual nuances encountered during NE, with the hope that this engenders an appreciation of the versatility of NE as a diagnostic tool.

Benign Spindle Cell Lesion of the Nasal Cavity: A Rare Presentation of Solitary Fibrous Tumor.

Solitary fibrous tumors (SFTs) are rare neoplasms primarily found in the pleural region but have been documented in diverse extrapleural sites, including the nasal cavity and paranasal sinuses, albeit infrequently. Here, we present a case of a 48-year-old female who presented with a right-sided nasal mass and associated ophthalmologic symptoms, ultimately diagnosed with a benign spindle cell lesion localized to the nasal cavity. The patient underwent a comprehensive evaluation involving clinical examination, radiological imaging, and histopathological analysis, leading to the identification of a benign solitary fibrous tumor. Notably, diagnosing SFTs in the nasal cavity presents challenges due to their nonspecific clinical and imaging features, necessitating a multidisciplinary approach for accurate diagnosis and optimal management. Surgical excision, preferably via endoscopic techniques, remains the cornerstone of treatment based on tumor characteristics and extent. This case underscores the importance of recognizing uncommon presentations of sinonasal lesions, navigating diagnostic complexities, and emphasizing the critical role of multidisciplinary collaboration in achieving favorable treatment outcomes for patients with such nasal cavity tumors.

Utilizing child-centered nursing care approaches for pediatric ENT patients undergoing nasal endoscopy.

OBJECTIVE: To investigate whether the child-centered treatment significantly increased satisfaction as revealed by CBCL scores and decreased duration of nasal endoscopy. METHODS: A total of 206 pediatric patients were selected as study participants. Using a random number table, the participants were divided into the control group and the treatment group, with 103 cases in each group. The control group received routine nursing care, whereas the treatment group received child-centered health education nursing intervention. The differences between the two groups were observed in four aspects: examination compliance, child behavior checklist (CBCL) scores, the satisfaction level of the patient's family with the nurses in the endoscopy room, and the average duration of the nasal endoscopy. RESULTS: Subsequent to the implementation of the intervention, it was observed that within the treatment group, the level of compliance among pediatric patients undergoing nasal endoscopy exhibited a statistically significant increase when compared to the control group; the CBCL scores of both groups were lower than those before nursing care, and those of the treatment group were statistically significantly lower than those of the control group; the satisfaction rate of the patient's family in two groups was 74 % and 90 %, respectively. The average duration of nasal endoscopy was statistically significantly lower in the treatment group than that in the control group. CONCLUSIONS: The implementation of a child-centered health education nursing intervention for pediatric patients undergoing nasal endoscopy has been shown to effectively mitigate instances of crying and screaming, enhance patient compliance, reduce examination duration, and elevate the overall satisfaction levels among their respective families.

Deep learning model for differentiating nasal cavity masses based on nasal endoscopy images.

BACKGROUND: Nasal polyps and inverted papillomas often look similar. Clinically, it is difficult to distinguish the masses by endoscopic examination. Therefore, in this study, we aimed to develop a deep learning algorithm for computer-aided diagnosis of nasal endoscopic images, which may provide a more accurate clinical diagnosis before pathologic confirmation of the nasal masses. METHODS: By performing deep learning of nasal endoscope images, we evaluated our computer-aided diagnosis system's assessment ability for nasal polyps and inverted papilloma and the feasibility of their clinical application. We used curriculum learning pre-trained with patches of nasal endoscopic images and full-sized images. The proposed model's performance for classifying nasal polyps, inverted papilloma, and normal tissue was analyzed using five-fold cross-validation. RESULTS: The normal scores for our best-performing network were 0.9520 for recall, 0.7900 for precision, 0.8648 for F1-score, 0.97 for the area under the curve, and 0.8273 for accuracy. For nasal polyps, the best performance was 0.8162, 0.8496, 0.8409, 0.89, and 0.8273, respectively, for recall, precision, F1-score, area under the curve, and accuracy. Finally, for inverted papilloma, the best performance was obtained for recall, precision, F1-score, area under the curve, and accuracy values of 0.5172, 0.8125, 0.6122, 0.83, and 0.8273, respectively. CONCLUSION: Although there were some misclassifications, the results of gradient-weighted class activation mapping were generally consistent with the areas under the curve determined by otolaryngologists. These results suggest that the convolutional neural network is highly reliable in resolving lesion locations in nasal endoscopic images.

Work-Related Musculoskeletal Injury Rates, Risk Factors, and Ergonomics in Different Endoscopic Specialties: A Review.

Endoscopy-related musculoskeletal injuries (ERIs) are frequent among gastrointestinal, pulmonary, nasal, and urologic endoscopists, impacting the healthcare system. The present review aims to compare the ERI rates, risk factors, and ergonomic recommendations in the different endoscopic fields. A review was conducted using PubMed and Cochrane Library for articles based on surveys and published until 10 January 2024. Demographic, work, and ERI data from 46 publications were included, covering 10,539 responders. The ERI incidence ranged between 14% and 97%, highlighting the need of intervention independent of the specialties. The neck, back, and shoulder were the most frequent ERI locations, while gender, age, years of experience, and procedure volume the most common risk factors. Ergonomic recommendations suggest concentrating on endoscope design changes, especially in gastrointestinal endoscopy, to increase the comfort, adaptability of the equipment in the operating room, and workflow/institutional policy changes. The inclusion of an ergonomic timeout guarantees the correct equipment positioning, the neutralisation of the endoscopist's posture, and an indirect break between procedures. Ergonomic training to increase awareness and best practice should be promoted, also using new technologies. Future research should concentrate on intervention and comparative studies to evaluate to which extent prevention measures and newly designed equipment could reduce ERI incidence.

The Use of Hand-Held Digital Otoscope as a Basic Nasal Endoscopy Tool for Lacrimal Evaluation and Pedagogy Instrument.

PURPOSE: To investigate the utility of a hand-held digital otoscope for nasal endoscopy and as a pedagogy tool for residents and fellows in patients undergoing external dacryocystorhinostomy (DCR) surgery. METHODS: A digital otoscope (MS450-NTE, Teslong Inc., USA) comprising a digital screen device and a connectible camera probe was used for performing nasal endoscopy. Inspection of nasal cavities was performed pre-, intra-, and post-operatively in sequential patients with nasolacrimal duct obstruction, who underwent DCR or lacrimal probing. Images (1920 × 1080 pixels) and videos (1280 × 720 pixels) were captured. The device was also used for training residents and fellows in performing nasal endoscopy, and to teach basic concepts. RESULTS: The digital otoscope could be used for routine outpatient nasal examination and for performing minor procedures. 53.8% (n = 13) of ophthalmology trainees had never observed nasal endoscopy and 84.6% could not identify more than one major structure correctly prior to the current training. Post-training, all trainees could independently perform nasal endoscopy with the device and 76.9% identified all structures correctly. CONCLUSION: A digital otoscope with a camera probe is a handy tool for nasal endoscopy and pedagogy. Low-cost gadgets such as this device can effectively be used for performing outpatient nasal endoscopy when expensive endoscopes are unavailable and in peripheral healthcare centers.

Diagnostic accuracy of clinical visual assessment using endoscopic images for nasal cavity mass lesions.

Objectives: Discrimination of nasal cavity lesions using nasal endoscopy is challenging because of the differences in clinical manifestations and treatment strategies. We aimed to investigate the diagnostic accuracy of clinical visual assessment (CVA) of nasal cavity masses using endoscopic images and determine whether there is a difference according to pathologic class and the examiners' experience. Methods: We collected pathologically confirmed endoscopic images of normal findings, nasal polyp (NP), benign tumor, and malignant tumor (each class contained 100 images) randomly selected. Eighteen otolaryngologists, including six junior residents, six senior residents, and six board-certified rhinologists classified the test set images into four classes of lesions by CVA. Diagnostic performance according to the pathologic class and the examiner's experience level was evaluated based on overall accuracy, F1-score, confusion matrix, and area under the receiver operating characteristic curve (AUC). Results: Diagnostic performance was significantly different according to the pathological class of nasal cavity mass lesions with the overall accuracy reported high in the order of normal, NP, benign tumor, and malignant tumor (0.926 ± 0.100; 0.819 ± 0.135; 0.580 ± 0.112; 0.478 ± 0.187, respectively), F1 score (0.937 ± 0.076; 0.730 ± 0.093; 0.549 ± 0.080; 0.554 ± 0.146, respectively) and AUC value (0.96 ± 0.06; 0.84 ± 0.07; 0.70 ± 0.05; 0.71 ± 0.08, respectively). The expert rhinologist group achieved higher overall accuracy than the resident group (0.756 ± 0.157 vs. 0.680 ± 0.239, p < .05). Conclusion: CVA for nasal cavity mass was highly dependent on the pathologic class and examiner's experience. The overall accuracy was reliably high for normal findings, but low in classifying benign and malignant tumors. Differential diagnosis of lesions solely based on nasal endoscopic evaluation is challenging. Therefore, clinicians should consider further clinical evaluation for suspicious cases.

Prognostic Value of Polypoid Changes of the Middle Turbinate in Relapsed Nasal Polypi after FESS: A Prospective Cohort Study.

Introduction Despite the high level of patient satisfaction with functional endoscopic sinus surgery (FESS) and the clinical improvement, polyp recurrence is observed in 23% to 87% of patients and requires reoperation. Objective To assess the prognostic value of polypoid changes of the middle turbinate (PCMT) in relapse of paranasal sinus polyps in patients with chronic rhinosinusitis with nasal polyp (CRSwNP) after FESS and the effect of partial middle turbinectomy (PMT) on the outcome of surgery. Methods We conducted a prospective clinical study on 60 patients with CRSwNP with and without PCMT. The patients were allocated into three groups: group I included twenty patients without PCMT; group II, twenty patients with PCMT; and group III included twenty patients with PCMT submitted to PMT. The patients were evaluated endoscopically according to the Lund-Kennedy endoscopic scoring system, radiologically according to the Lund-Mackay scoring system, and symptomatically through the 22-item Sinonasal Outcome Test (SNOT-22). Results The total postoperative Lund-Kennedy score differed significantly among the 3 groups ( p < 0.001), with a group II presenting a significantly higher total score compared to groups I and III. The Preoperative SNOT-22 score differed significantly among the three groups ( p = 0.013), with group II presenting a significantly higher score compared to group I. There was a significant association involving the 3 groups and relapse at 12 months ( p = 0.029); relapse was higher in group II (50.0%) than in groups I (20%) and III (15.0%). Conclusion There was a significant association between PCMT and the relapse of nasal polyps. Also, nasal polyposis recurred at a lower rate in the group submitted to middle turbinate resection compared to the group in whom it was preserved.

Novel Grading System Based on Nasal Endoscopy: Our Experience with 650 Mucormycosis Cases.

Rhinocerebralmucormycosis, is a progressive fungal invasion of a hard palate, paranasal sinuses, orbit, and brain. Post covid the huge number of mucor cases reported in our institute. To combat them a uniform assessment scale was needed as multiple healthcare workers were involved. Thus, a novel linear grading system on nasal endoscopy was developed for the early management of patients to prevent morbidity and mortality. A Prospective study of 650 patients in Epidemic duration from April to June 2021 in a tertiary health center, Central India. Patients subjected to Nasal Endoscopy with 0degree 4 mm Telescope and classified into 5 categories according to the severity of the disease. In a novel grading system, minimum patients were of grade 0, maximum was in Grade I. Maxillary sinus was most commonly involved. This novel grading system on nasal endoscopy makes the management of patients much easier in an epidemic, reducing human errors, morbidity, and mortality of the fulminant disease.

Prelacrimal recess approach for maxillary sinus inverted papilloma: a 15-year experience from a single center.

PURPOSE: This large retrospective, single-center, follow-up study investigated the endoscopic prelacrimal recess approach (PLRA) for treating maxillary sinus inverted papilloma (MSIP). METHODS: Between January 2007 and November 2022, patients with MSIP treated with PLRA were enrolled. Data on clinical manifestations, imaging, and surgical procedures were collected. The visual analog scale (VAS) scores for maxillofacial numbness and nasal symptoms and the SNOT-22 nasal symptom scores were statistically analyzed. RESULT: Of 122 patients (68 males and 54 females) enrolled in the study, with a mean age of 50.75 ± 12.84 years (26-80 years), 111 patients underwent PLRA, nine underwent modified PLRA, one converted to an endoscopic medial maxillectomy (EMM), and one to an endoscopic modified Denker's approach. The average follow-up was 86.60 (13-192) months, the recurrence rate was 3.28%, and 29 patients (23.77%) complained of maxillofacial numbness one month postoperatively, which disappeared in most cases one year after surgery. Five patients (4.10%) experienced mild numbness at the end of the follow-up period. Maxillary sinus ostium contracture or atresia occurred in two cases (1.64%). After surgery, the VAS nasal symptom scores improved significantly (P < 0.001). SNOT-22 indicated that the most common postoperative symptom was thick nasal discharge. CONCLUSION: PLRA is a flexible first-choice surgical treatment for maxillary sinus inverted papilloma and can be modified according to the extent of the lesion, the surgeon's experience and technique, and surgical instruments. That can help achieve complete resection and reduce recurrence and surgical complications. Upper teeth numbness, the most common postoperative complication, tends to disappear after 1 year.

Nasopharyngeal Cyst Causing Hearing Loss: Case Report and Review of Literature.

Symptomatic nasopharyngeal cysts are relatively uncommon. Here is a case report of 50 years of age female with hearing loss secondary to the nasopharyngeal cyst. She underwent endoscopic marsupialization and achieved normal hearing postoperatively.The study aims to determine the incidence of hearing loss, radiological patterns and histopathological findings associated with the nasopharyngeal cyst.

Schwannoma of Nasopharynx-A Rare Case with A Complex Presentation.

Nasopharyngeal tumors are rare, and schwannomas originating from this location are extremely uncommon. Schwannomas are tumors arising from the Schwann cells of peripheral nerve sheath which are neuroectodermal in origin. These are benign, slow growing, well-encapsulated tumors and are mostly seen in the head and neck region. We present a rare case of schwannoma with nasopharynx as its epicenter in an elderly female patient who presented with complaints of hematemesis, bilateral nasal obstruction and stertorous breathing. Diagnostic nasal endoscopy revealed a smooth mucosa covered globular mass occupying bilateral choana. Contrast-enhanced computed tomography of Nose and paranasal sinuses revealed a homogenous mass occupying the entire nasopharynx extending into the nasal and oropharyngeal cavities. The patient underwent Trans-nasal Endoscopic excision under general anesthesia. Nasopharyngeal tumors have a wide range of presentation and a high index of clinical suspicion combined with imaging modalities is required for diagnosis and pre operative planning. Some tumors can cause life-threatening airway obstruction due to delayed presentation and should be managed efficiently and meticulously, with endoscopic excision being a viable approach for cases confined within the nasopharynx.

[Characteristics and therapeutic strategies of Pott's puffy tumor].

Objective:To explore the characteristics and therapeutic strategies of Pott's puffy tumor（PPT）. Methods:The clinical data of two patients with PPT were retrospectively analyzed and combined with the literature, focusing on the comprehensive analysis of perioperative diagnosis and treatment strategies. Both patients underwent muti-disciplinary treatment, including timely administration of sufficient antibiotics capable of penetrating the blood-brain barrier. Early removal of PPT lesions was performed using a combined internal and external approach under nasal endoscopic guidance. Results:After standardized perioperative management, the symptoms of the two patients were completely relieved, with no recurrence after one=year follow=up. Postoperative complications such as frontal pain, numbness, local depression, or scar hyperplasiawere not present. Conclusion:PPT, being relatively rare and severe, requires careful attention. Key strategies for standardized perioperative management include multi-disciplinary consultation, timely and adequate antibiotic administration, and surgical intervention using a combined intranasal and extranasal endoscopic approach for lesion removal.