Botulinum Toxin-Induced Parotitis: A Postoperative Complication Following Masseter Muscle Injection.

Botulinum toxin (BTX) injection is a common treatment for bruxism, but there is no literature on potential salivary gland complications. This paper presents a case of acute parotitis in a 60-year-old female following BTX injections to the masseter muscle. This case highlights the possible salivary gland complications after injection of BTX into the masticatory muscles. An electronic search of PubMed and Embase databases was conducted to create a literature review in order to delve into the etiology behind the presented case and suggest potential preventive measures to avoid salivary gland complications. Thirty-one articles are reviewed and discussed. Currently, there is no consensus on the causes of the mentioned complication. However, various factors have been proposed, encompassing anatomical, physiological, biological, and physical aspects. Several methods have been recommended for the safe injection of BTX, which, along with better medical training and knowledge, are warranted to achieve predictable results.

Direct Transvestibular Feminization Thyroid Laryngochondroplasty.

BACKGROUND: Feminization laryngochondroplasty (FLC) methods have evolved from using a midcervical incision to a submental, less visible incision. The scar may be unacceptable to the patient because it signals gender reassignment surgery. An endoscopic transoral approach to FLC inspired by transoral endoscopic thyroidectomy was recently suggested to avoid the neck scar; however, it requires special equipment and has a long learning curve. A vestibular incision is used to approach the chin in lower-third facial feminization surgery. The authors propose that this incision may be extended to the thyroid cartilage in performing direct FLCs. The authors describe their experience with a novel, minimally invasive, direct transvestibular use of the chin-reshaping incision. METHODS: The medical records of all patients who underwent direct transvestibular FLC (DTV-FLC) from December of 2019 to September of 2021 were retrieved and reviewed for this retrospective cohort study. Data on the operative, postoperative, and follow-up courses, complications, and functional and cosmetic results were retrieved. RESULTS: Nine transgender women were included. Seven DTV-FLCs were performed during lower-third facial feminization surgery, and two were isolated DTV-FLCs. One was a revision DTV-FLC. Transient minor complications were encountered and resolved by the postoperative visit at 1 to 2 months. Vocal fold function and voice quality remained intact. Eight available patients were satisfied with the surgical results. A blinded assessment by eight plastic surgeons determined that seven procedures were successful. CONCLUSION: The novel DTV-FTLC approach either in isolation or as part of lower-third facial feminization surgery facilitated scar-free FLC with satisfactory cosmetic and functional results. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Risk Factors for Postsurgical Infections in Facial Feminization Surgery.

BACKGROUND: Facial feminization surgical procedures are involving several surgical disciplines in multiple surgical sites and therefore may carry the risk of developing infections. Data on the development of postsurgical infection (PSI) and contributing factors in male-to-female transgender people (transwomen) undergoing facial feminization surgery are scarce. The aim of this study was to investigate the contributing factors to develop PSIs in facial feminization surgical procedures. METHODS: Data from the medical records of 40 transwomen who underwent facial feminization surgeries in our institution between 2019 and 2021 were analyzed. The independent variables included demographic parameters (weight, body mass index, medical comorbidities and age), details of the surgical procedure (type, duration and whether another procedure had been performed concomitantly), type, dosage and route of administration of postoperative antibiotics and steroids, length of hospitalization and follow-up duration. Postsurgical infection was designated a dependent variable. RESULTS: Five out of 40 patients (12.5%) developed PSI. The surgery of those with PSIs involved more sites, and the duration of nasal tamponade was more than four times longer than for patients who did not develop a PSI. CONCLUSIONS: The current study revealed higher postsurgical infections rates after lengthy surgeries or when it involves several surgical facial feminization procedures. Multicenter clinical trial on a big cohort may enable better evidence-based results. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Data From a One-Stop-Shop Comprehensive Cancer Screening Center.

PURPOSE: Cancer is the second leading cause of death globally. However, by implementing evidence-based prevention strategies, 30%-50% of cancers can be detected early with improved outcomes. At the integrated cancer prevention center (ICPC), we aimed to increase early detection by screening for multiple cancers during one visit. METHODS: Self-referred asymptomatic individuals, age 20-80 years, were included prospectively. Clinical, laboratory, and epidemiological data were obtained by multiple specialists, and further testing was obtained based on symptoms, family history, individual risk factors, and abnormalities identified during the visit. Follow-up recommendations and diagnoses were given as appropriate. RESULTS: Between January 1, 2006, and December 31, 2019, 8,618 men and 8,486 women, average age 47.11 ± 11.71 years, were screened. Of 259 cancers detected through the ICPC, 49 (19.8%) were stage 0, 113 (45.6%) stage I, 30 (12.1%) stage II, 25 (10.1%) stage III, and 31(12.5%) stage IV. Seventeen cancers were missed, six of which were within the scope of the ICPC. Compared with the Israeli registry, at the ICPC, less cancers were diagnosed at a metastatic stage for breast (none v 3.7%), lung (6.7% v 11.4%), colon (20.0% v 46.2%), prostate (5.6% v 10.5%), and cervical/uterine (none v 8.5%) cancers. When compared with the average stage of detection in the United States, detection was earlier for breast, lung, prostate, and female reproductive cancers. Patient satisfaction rate was 8.35 ± 1.85 (scale 1-10). CONCLUSION: We present a proof of concept study for a one-stop-shop approach to cancer screening in a multidisciplinary outpatient clinic. We successfully detected cancers at an early stage, which has the potential to reduce morbidity and mortality as well as offer substantial cost savings.[Media: see text].

Maxillofacial Injuries Sustained by Riders of Electric-Powered Bikes and Electric-Powered Scooters.

OBJECTIVES: The purpose of our study is to retrospectively analyze and compare the patterns of maxillofacial-related injuries among rides of electric-powered bikes (E-bikes) and electric-powered scooters (E-scooters), the associated risk factors, and the required treatment. MATERIALS AND METHODS: The medical files of all riders presenting to the emergency department at the Tel Aviv Sourasky Medical Center between 2019 and 2020 with oral- and maxillofacial-related injuries due to E-bike and E-scooter accidents were reviewed. RESULTS: A total of 320 riders sustained oral- and maxillofacial-related injuries due to trauma involving E-bikes and E-scooters during the study period. E-scooter riders were involved in 238 accidents (74.5%) while E-bike riders accounted for the remaining 82 accidents (27.5%). Eighty-four out of 320 riders (26.25%) were hospitalized and required surgical interventions. Most of the 232 riders (72.5%) who reported not wearing a protective helmet during the index accident were E-scooter riders. In addition, 39 riders (18.66%) were riding either of these electric-powered vehicles under the influence of alcohol. CONCLUSIONS: E-bike riders are more likely to sustain a maxillofacial fracture than E-scooter riders. Not wearing a protective helmet and riding under the influence of alcohol are major risk factors for maxillofacial injuries.

Vertical Ramus Osteotomy, Is It Still a Valid Tool in Orthognathic Surgery?

The purpose of this study is to evaluate mandibular osteotomy procedures during orthognathic surgery, with an emphasis on the complications of the two leading procedures: intraoral vertical ramus osteotomy (IVRO) and sagittal split osteotomy (SSO). We conducted a retrospective cohort study by extracting the records of patients who underwent either IVRO or SSO procedures during orthognathic surgery in a single center between January 2010 and December 2019. A total of 144 patients were included (median age of 20.5 years, 52 males). The IVRO:SSO ratio was 118:26 procedures. When referring to all surgeries performed, IVRO procedures were associated with shorter hospitalization than the SSO procedures, while the overall durations of surgery and follow-up periods were comparable. In contrast, when referring only to bimaxillary procedures, the duration of the IVRO bimaxillary procedures was significantly shorter than the SSO bimaxillary procedures. There were 53 complications altogether. Postoperative complications consisting of skeletal relapse, temporomandibular joint dysfunction, sensory impairment, and surgical-site infection were significantly fewer in the IVRO group. Both types of osteotomies have acceptable rates of complications. IVRO appears to be a safer, simpler, though less acceptable procedure in terms of patient compliance.

The rate of occult nodal metastasis in submandibular gland malignancies: A case series and meta-analysis.

OBJECTIVE: Submandibular gland (SMG) malignancies are exceedingly rare. Lymph node metastasis is one of the most important determinants of outcome in SMG malignancies. The aim of this study was to investigate the overall rate of occult neck nodal metastasis in SMG malignancies. STUDY DESIGN: The study design is a meta-analysis of all studies on patients with a primary SMG malignancy, without evidence of neck nodal metastasis, who underwent an elective neck dissection (END). The search strategy identified 158 papers that appeared in print from January 1980 to July 2020. All eligible patients from the Tel-Aviv Medical Center were analyzed and consolidated into a case series. A total of 12 retrospective studies that included 306 suitable patients met inclusion criteria. RESULTS: The risk for occult metastasis in primary SMG malignancies was 0.0% to 50.0%, with a fixed effect model of 19.52% (95% CI, 14.9%-24.5%). The analyzed studies included a wide range of pathologies. The most common malignancies were adenoid cystic carcinoma and mucoepidermoid carcinoma. CONCLUSIONS: The overall rate of occult neck metastasis in SMG malignancies is relatively high, and an END should be the default intervention in these cases. An END is unwarranted in tumors judged clinically to be low stage and low grade.

Acinar Atrophy, Fibrosis and Fatty Changes Are Significantly More Common than Sjogren's Syndrome in Minor Salivary Gland Biopsies.

Background and Objective: Hyposalivation and xerostomia can result from a variety of conditions. Diagnosis is based on a combination of medical history, clinical and serological parameters, imaging, and minor salivary gland biopsy when indicated. The Objective was to characterize microscopic changes in minor salivary gland biopsies taken in patients with xerostomia. Materials and Methods: 10-year retrospective analysis of minor salivary gland biopsies, 2007-2017. Histomorphometric analysis included gland architecture, fibrosis, fat replacement, inflammation and stains for IgG/IgG4, when relevant. Results: 64 consecutive biopsies, of which 54 had sufficient tissue for diagnosis of Sjogren's Syndrome (SS) were included (18 males, 46 females, average age 56 (±12.5) years). Only 12 (22.2%) were microscopically consistent with SS, none stained for IgG4. Medical conditions were recorded in 40 (63%), most frequently hypertension and hyperlipidemia (28% each). Medications were used by 45 (70%), of which in 50% more than one. Xerostomia in non-SS cases was supported by abnormal gland morphology, including acinar atrophy, fibrosis and fatty replacement. All morphological abnormalities are correlated with age, while fatty replacement correlated with abnormal lipid metabolism. Multiple medications correlated with microscopic features which did not correspond with SS. Conclusions: SS was confirmed in a minority of cases, while in the majority fatty replacement, fibrosis and multiple medications can explain xerostomia, and are related to aging and medical conditions. Medical history and auxiliary tests could lead to correct diagnosis in non-SS patients, avoiding biopsy. The necessity of a diagnostic biopsy should be given serious consideration only after all other diagnostic modalities have been employed.

Winds of Change in Antibiotic Therapy following Orthognathic Surgery.

Background and objectives: This retrospective cohort study aimed to compare three postoperative antibiotic protocols of different durations on surgical-site-infection (SSI) rates following orthognathic surgery for the correction of jaw deformities. Materials and methods: An analysis on data collected from the medical files of 209 patients who underwent orthognathic surgery between 2010 and 2019 was conducted. The patients were divided into three groups according to the postoperative antibiotic protocol-Group 1 (24 h), Group 2 (2-3 days), and Group 3 (>3 days). Dependent and independent variables were collected, analyzed, and compared between the three groups. Results: Group 1 included 30 patients (14.3%), Group 2 included 123 patients (58.9%), and Group 3 included 56 patients (26.8%). The vast majority of the postoperative antibiotics were amoxicillinand clavulanic acid (87.1%). The duration of the surgery and the use of a feeding tube were significantly different between Groups 1 and 3 (p < 0.001 and p = 0.005, respectively). There was no significant difference in SSI rates between the three groups (p = 0.642). The use of antibiotics beyond the immediate postoperative period provides no increased benefit regarding infection prevention. Conclusions: In young and healthy patients undergoing orthognathic surgery, a 24hregimen of postoperative antibiotics may be sufficient.

IgG4-related sialadenitis - a rare bilateral submandibular gland enlargement: case report.

Immunoglobulin G4-related disease (IgG4-RD) is a fibroinflammatory condition of unknown etiology. Although the salivary glands are currently considered among the most commonly affected among them, oral and maxillofacial surgeons are generally not familiar with the condition. Enlargement of the major salivary glands may be the first identifiable sign of IgG4-RD. A salivary gland biopsy along with IgG4 serum level assessment may help differentiate IgG4-related sialadenitis (IgG4-RS) from malignancies, infectious diseases, and obstructive conditions. Greater knowledge and higher levels of awareness of IgG4-RS may contribute to the expansion of differential diagnostic and treatment approaches. This case report describes a patient with bilateral submandibular salivary gland swelling who was diagnosed as having IgG4-RS on the basis of the histopathologic findings of a submandibular salivary gland biopsy and subsequent IgG4 levels.

Retrospective Clinicopathological Analysis of 65 Peri-Implant Lesions.

Background and Objectives: Peri-implantitis is a common finding among patients with dental implants. There is no consensus regarding the treatment of this disease, but in many cases, surgical treatment is common practice. A histopathological analysis is not an integral part of suggested protocols. The present study investigated the clinical and histopathological parameters of lesions mimicking peri-implantitis and correlated them with the outcome and follow-up data. Materials and Methods: The study included 65 consecutive biopsies taken from peri-implantitis patients between 2008-2019. Results: The three common diagnoses were fibro-epithelial hyperplasia 20 (30.7%), pyogenic granuloma 16 (24.6%), and peripheral giant cell granuloma 15 (23%). There were 18 cases of recurrent lesions in the study group (27.7%). The recurrence rate was the highest in peripheral giant cell granuloma (8, 12.3%), versus 6% in pyogenic granuloma and fibro-epithelial hyperplasia. These differences in the recurrence rate were statistically significant (p = 0.014). Conclusions: This study emphasizes the necessity of submitting tissue of peri-implantitis cases for histopathological analysis since the more locally aggressive lesions (peripheral giant cell granuloma and pyogenic granuloma), which comprise nearly half of the cases in this study, do not differ in clinical or radiographic characteristics from other peri-implant lesions.

Three-dimensional intraoperative computed tomography imaging for zygomatic fracture repair.

OBJECTIVES: Zygomatic complex (ZMC) fractures comprise up to 40% of all facial fractures. Misaligned bone fragments and misplaced fixation hardware traditionally detected postoperatively on plain radiographs of the skull might require re-operation. The intraoperative O-Arm (Medtronic, USA) is a three-dimensional (3D) computed tomographic imaging system. MATERIALS AND METHODS: This retrospective single-center study evaluated the utility of O-Arm scanning during corrective surgeries for ZMC and zygomatic arch (ZA) fractures from 2018 to 2020. Three females and 16 males (mean age, 31.52 years; range, 22-48 years) were included. Fracture instability (n=6) and facial deformity (n=15) were the most frequent indications for intraoperative 3D O-Arm scan. RESULTS: The images demonstrated that all fracture lines were properly reduced and fixed. Another scan performed at the end of the fixation or reduction stage, however, revealed suboptimal results in five of the 19 cases, and further reduction and fixation of the fracture lines were required. CONCLUSION: Implementation of an intraoperative O-Arm system in ZMC and ZA fracture surgeries assists in obtaining predictable and accurate results and obviates the need for revision surgeries. The device should be considered for precise operations such as ZMC fracture repairs.

Short Versus Extended Antibiotic Prophylaxis for Maxillary Sinus Floor Augmentation Via a Lateral Window Approach: A Randomized Controlled Trial.

PURPOSE: The purpose of this randomized controlled trial was to compare the surgical site infection rate with short (24 hours) vs extended (7 days) antibiotic prophylaxis for maxillary sinus floor augmentation surgery. MATERIALS AND METHODS: Eighty-five patients who were candidates for unilateral or bilateral maxillary sinus floor augmentation surgery were randomly assigned to short or extended antibiotic prophylaxis. Patients were evaluated on days 7, 14, 30, 60, and 180 after surgery for symptoms and signs of infection. The primary study endpoint was the development of surgical site infection up to day 180 postoperatively. RESULTS: Patients underwent a total of 117 maxillary sinus floor augmentation surgeries, 62 in the short prophylaxis arm and 55 in the extended prophylaxis arm. Fifty-three patients (62%) had unilateral surgery, and 32 (38%) had bilateral surgery. Three patients developed a surgical site infection by 180 days postsurgery (overall rate, 2.6%): one patient (1.6%) in the 24-hour arm and two (3.6%) in the extended prophylaxis arm. All three patients received antibiotic treatment, and the infections resolved entirely. CONCLUSION: A low rate of surgical site infection was observed after maxillary sinus floor augmentation, and there was no apparent advantage to extended (7 days) vs short (24 hours) duration of antibiotic prophylaxis. The findings do not support the use of extended postprocedural chemoprophylaxis for patients undergoing maxillary sinus floor augmentation.

Knowledge and Associated Factors about Rare Diseases among Dentists in Israel: A Cross Sectional Survey.

Aim: The current study aims to assess levels of knowledge among Israeli dentists about rare diseases with orofacial manifestations, and whether occupational, regional and social factors influence those levels. Materials and Methods: A total of 309 Israeli dentists participated in an online survey that provided basic demographic information pertaining to their knowledge about rare diseases, their clinical experience with rare diseases, what further information they considered necessary, and which sources of information they most frequently utilize. Results: Young age, country of dental education, practicing in both public and private settings, as well as the number of hours allocated to dental studies and the opportunity to acquire information on rare diseases with orofacial manifestations, all seem to affect the level of knowledge. Conclusions: Developments in the field of rare disease are constantly ongoing, and improvements in post-graduate dental studies about them should keep pace. The results of the current study reveal the areas upon which such curricula should focus with respect to dental practitioners.

Orthognathic surgery complications: The 10-year experience of a single center.

The retrospective cohort study aimed to assess the incidence and characteristics of these complications in patients who underwent orthognathic procedures. Data on the intraoperative and the postoperative complications were extracted from the patients' medical files. Procedures were further subdivided into single-jaw procedures and bimaxillary procedures. A total of 209 orthognathic procedures were carried out in 190 patients. 184 (88%) were performed to treat angle class III malocclusion, while 25 (12%) aimed to treat class II malocclusion. A total of 94 complication events were observed (44.9% of 209 procedures). 22 of them occurred in single-jaw procedures (28.2% of 78 single jaw operations), and 72 occurred in bimaxillary procedures (55% of 131 bimaxillary operations). When compared regarding the type of complication, complication rates were comparable between the study groups with the exception of late-stage malocclusion. A significant difference (p-value = 0.028) in malocclusion incidences between the bimaxillary and single-jaw groups were observed (9 events, 4.3% and zero events, 0%, respectively). The majority of the complications during and following orthognathic surgical procedures are temporary or minor and require little or no treatment at all.

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.

Continuous tooth eruption adjacent to single-implant restorations in the anterior maxilla: aetiology, mechanism and outcomes - A review of the literature.

INTRODUCTION: Dental trauma and congenital anodontia are common causes of anodontia in the anterior maxilla. The proposed restorative treatment constitutes a challenge for many dentists, particularly if it is a question of a young patient who has not yet completed skeletal and dental development. Current treatments for anterior maxillary anodontia include: fixed or removable partial dentures; orthodontic closure of interdental spaces; and dental implants. Dental implants do not move with the dento-alveolar complex during the growth period of the maxilla. Therefore, many researchers maintain that implants should be postponed until after adolescence, in order to prevent complications, such as infra-occlusion, that would require the replacement of the abutment and crown-implant restoration, or even invasive treatments, such as the removal of the implant in the future. The objective of this literature review is to investigate the aetiology of the phenomenon, and outcome. RESULTS: Continuous tooth eruption is not affected by age, so considerable changes may occur due to eruption of adjacent teeth. In addition, both women and men are affected by this phenomenon and, usually, there is no significant difference in the amount of growth between the short face and the long face. CONCLUSION: It can be concluded that continuous facial skeletal growth and teeth eruption are evident in the second and third decades. Where possible, it is advisable to delay placement of an anterior maxillary implant in the adolescent patient.

Questioning the Justification of Frontal Sinusotomy for Odontogenic Sinusitis.

PURPOSE: Odontogenic sinusitis (OS) can be caused by infectious conditions of the posterior maxillary teeth. The maxillary sinus has been most often involved because of its proximity to the posterior maxillary teeth. Often the anterior ethmoids and frontal sinuses will be involved by the infective process. The underlying odontogenic condition must be addressed before or during sinus surgery. The role of frontal sinusotomy in the treatment of these patients has been poorly described. Our objective was to present the surgical outcomes of patients with OS involving the frontal sinus who had undergone middle meatal antrostomy alone. PATIENTS AND METHODS: A prospective analysis of all patients who had undergone surgery at a single tertiary center to treat OS involving the frontal sinus from November 2015 to December 2018 was performed. Their preoperative assessment findings, surgical findings, and postoperative outcomes were analyzed. RESULTS: A total of 45 patients (23 men and 22 women), with a median age of 57 years (range, 20 to 83 years), were enrolled in the present study. All anterior sinuses (frontal, anterior ethmoids, and maxillary sinuses) were clinically and radiographically involved in all the patients. Each patient underwent endoscopic wide maxillary middle meatal antrostomy concurrent with dental intervention. The average follow-up was 7 months. No signs of active frontal disease were detected by postoperative endoscopy in any patient, and no patient required revision surgery. CONCLUSIONS: The results from the present study have shown that no justification exists for frontal sinusotomy for the treatment of OS involving the frontal sinus. Frontal sinusitis is a secondary infectious and inflammatory process that will resolve once the underlying odontogenic condition has healed and wide middle meatal antrostomy has been performed.

Odontogenic sinusitis involving the frontal sinus: is middle meatal antrostomy enough?

OBJECTIVE/HYPOTHESIS: Inflammatory conditions of the posterior maxillary teeth may cause odontogenic sinusitis (OS), which most commonly involves the maxillary sinus due to its proximity to those teeth. The infective process frequently spreads outside the maxillary sinus, involving the anterior ethmoid and the frontal sinuses. The underlying odontogenic condition must be addressed before or during the surgical procedure. The role of frontal sinusotomy in this setting has not been studied. The aim of this study is to present the surgical outcome of patients who presented with OS involving the frontal sinus and were managed by middle meatal antrostomy alone. STUDY DESIGN: Prospective cohort study. METHODS: All patients operated in our department due to OS involving the frontal sinus from November 2015 to December 2017 were recruited. Their demographics, complaints, imaging and endoscopic findings, surgical features and outcome were analyzed. RESULTS: Twenty-five patients (male-to-female ratio 9:16) with a median age of 49 years (IQR = 43-53) were enrolled. The maxillary, frontal and anterior ethmoid sinuses were involved in each case, and each patient underwent maxillary middle meatal antrostomy alone. The median follow-up was 10 months, and no signs of active frontal disease were detected by postoperative endoscopy in any patient. CONCLUSION: Frontal sinusotomy is apparently not necessary to resolve OS involving the frontal sinus. The frontal sinusitis may reflect a reactive process that regresses spontaneously once the underlying odontogenic condition is addressed and a middle meatal antrostomy had been performed. LEVEL OF EVIDENCE: 2B.