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.

Laryngectomy-free survival after salvage partial laryngectomy: a systematic review and meta-analysis.

PURPOSE: Radiotherapy (RT) is widely used for early glottic cancer. Patients failing this treatment are referred to surgical management of their disease. Salvage partial laryngectomy (SPL) has the advantage of preserving laryngeal function with total laryngectomy (TL) remaining as a last resort. The purpose of this study was to determine the efficacy of SPL in preventing total laryngectomy, following failed RT, for early glottic cancer. METHODS: A meta-analysis of all published English literature was performed. All publications that included patients undergoing SPL were reviewed according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) reporting guidelines. The search strategy identified 154 relevant articles. A total of 15 retrospective studies that included 323 suitable patients were subsequently analyzed in this meta-analysis. The main outcome measure was the rate of laryngectomy-free survival (LFS) following SPL. The indications for salvage TL (i.e., disease recurrence and poorly functional larynxes) as well as subgroup analyses for open and trans-oral SPLs were also calculated. RESULTS: The overall rate of LFS following SPL was 81.2% (fixed effects model range: 75.7-86.8%). Salvage TL following SPL were performed in 96.8% due to disease recurrence and in 3.2% to poorly functional larynxes. A subgroup analysis showed a 90.4% LFS after open SPL and 78.6% following trans-oral SPL. CONCLUSION: A high rate of successful salvage partial laryngectomies, regardless of surgical technique, is to be anticipated in well-selected patients after RT failure.

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.

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.

Diagnosing odontogenic sinusitis: An international multidisciplinary consensus statement.

BACKGROUND: Odontogenic sinusitis (ODS) is distinct from non-odontogenic rhinosinusitis, and often requires multidisciplinary collaboration between otolaryngologists and dental providers to make the diagnosis. The purpose of this study was to develop international multidisciplinary consensus on diagnosing ODS. METHODS: A modified Delphi method was used to assess for expert consensus on diagnosing bacterial ODS. A multidisciplinary panel of 17 authors with ODS expertise from 8 countries (8 otolaryngologists, 9 dental specialists) was assembled. Each author completed 2 of 3 surveys (2 specialty-specific, and 1 for all authors). Thirty-seven clinical statements were created, focusing on 4 important diagnostic components: suspecting ODS; confirming sinusitis in ODS; confirming different dental pathologies causing ODS; and multidisciplinary collaborative aspects of diagnosing ODS. Target audiences were all otolaryngologists and dental providers. RESULTS: Of the 37 clinical statements, 36 reached consensus or strong consensus, and 1 reached no consensus. Strong consensus was reached that certain clinical and microbiologic features should arouse suspicion for ODS, and that multidisciplinary collaboration between otolaryngologists and dental providers is generally required to diagnose ODS. To diagnose ODS, otolaryngologists should confirm sinusitis mainly based on nasal endoscopic findings of middle meatal purulence, edema, or polyps, and dental providers should confirm dental pathology based on clinical examination and dental imaging. CONCLUSION: Based on multidisciplinary international consensus, diagnosing ODS generally requires otolaryngologists to confirm sinusitis, and dental providers to confirm maxillary odontogenic pathology. Importantly, both dental providers and otolaryngologists should suspect ODS based on certain clinical features, and refer patients to appropriate providers for disease confirmation.

The Efficiency of Routine Histopathological Examination for Bilateral Nasal Polyposis.

The necessity to routinely carry out histopathologic examinations of surgically removed polyps in patients with chronic rhinosinusitis with bilateral nasal polyps (CRSwNP) is uncertain. The aim of this study was to describe the histopathology of polyps from a large series of patients who underwent endoscopic sinus surgery for CRSwNP and the rate of neoplasms. This is a retrospective study of the histopathological result of all patients with CRSwNP who underwent functional endoscopic nasal surgery and in whom histologic examination was performed, from 2006 to 2015, in a tertiary medical center. Data on demographics and whether a nasal lesion was suspected for neoplasm prior to surgery were analyzed. Two hundred thirty-five patients underwent bilateral nasal polypectomy and histopathologic examinations of the surgical specimens. The rate of neoplasms in nonsuspicious cases was 2.3% (5 cases) and all were inverted papilloma. To conclude, inverted papilloma and other neoplasms are considered rare incidental findings in patients presenting with bilateral nasal polyps. This study demonstrated a higher rate of the latter than that reported in the literature. Our study further emphasizes that despite the low incidence of these pathologies, a histopathologic examination of every nasal polypectomy is warranted so as not to miss potential serious pathologies. We stress that a routine histopathological examination should be practiced at least in the elderly population.

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.

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.

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.

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.

Outcomes of Craniofacial Open Surgery in Octogenarians.

Introduction The steady increase in average life expectancy has led to a rise in the number of referrals of elderly patients for major operations. It is not clear whether age itself is a risk factor for morbidity and mortality after skull base operations. We investigated a possible link among a cohort of patients older than 80 years of age who underwent those surgeries in our department. Methods We conducted a retrospective analysis of all patients who underwent skull base surgery at the TASMC (Tel Aviv Sourasky Medical Center) between 2000 and 2016. Results A total of 369 patients underwent open skull base surgeries in our institution, and 13 were patients older than 80 years. The median age of the octogenarians was 83.4 (range 80-89), and the male-to-female ratio was 7:6. Twelve patients had major systemic comorbidities. Four patients had major complications associated with surgery: three had early wound complications, and one each had early central nervous system complications, early and late systemic complications, and late orbital complications. This complication rate is comparable to that of our younger group of 356 patients. The overall survival rate was measured for 30 days, 1 year, and 3 years, and it was not significantly different between the octogenarians and that of the younger patients. Further comparison of the elderly group with 13 matched younger patients revealed no difference of morbidity and mortality between the two groups. Conclusions Despite their systemic comorbidities, the morbidity and mortality rates associated with skull base surgery in octogenarians appear to be comparable to that of younger patients undergoing the same procedures.

Continuous lumbar drainage and the postoperative complication rate of open anterior skull base surgery.

OBJECTIVES/HYPOTHESIS: Anterior skull base operations pose the risk for postoperative cerebrospinal fluid (CSF) leak. Routine lumbar continuous drainage catheter (LD) placement is intended to decrease CSF leaks and central nervous system (CNS) complications, but there are no sound evidence-based data on its efficacy. The primary goal of this study was to review CNS complications following anterior open skull base surgery and their association with LD placement. The secondary goal was to define predictors for the development of early CNS complications. STUDY DESIGN: Retrospective case series. METHODS: We conducted a retrospective analysis of all patients who underwent anterior skull base surgery between 2000 and 2016 at the Tel Aviv Sourasky Medical Center, an Israeli tertiary referral center. RESULTS: A total of 226 patients underwent open skull base surgery, of whom 118 had elective perioperative continuous LD insertion and 108 did not. Delayed complications were defined as those occurring more than 30 days after the index operation. Thirty-one (26%) patients in the LD group had early CNS complications compared with only two (1.6%) in the non-LD group, whereas 13 (11%) of the former patients had late CNS complications compared with four (3%) of the latter patients. Early systemic and late wound complications were also significantly more numerous in the LD group. On multivariate analysis, elective LD insertion and intracranial tumor extension were found to be predictors for developing early CNS complications. CONCLUSIONS: The placement of continuous LDs might increase the risk of developing early and late CNS complications after open anterior skull base surgery. LEVEL OF EVIDENCE: 4 Laryngoscope, 128:2702-2706, 2018.

Enhanced visualization of the surgical field in pediatric direct laryngoscopy using a three-dimensional endoscopic system.

BACKGROUND: Direct laryngoscopy and rigid bronchoscopy are currently performed using 2-dimensional endoscopic systems. Our objective was to determine whether a 3-dimensional endoscopic system can enhance visualization of the surgical field in pediatric direct laryngoscopy and rigid bronchoscopy. METHODS: A prospective cohort study was conducted. Thirty three children who underwent direct laryngoscopies in a tertiary referral children's hospital were enrolled. Direct laryngoscopy was performed using both 2- and 3-dimensional endoscopic systems, after which the surgeons scored the quality of the images obtained with each system on a scale from 1 (low) to 5 (high). Comparison of the scores obtained with the 2 endoscopic systems was performed. RESULTS: The 33 study children (mean age 2.3 years, M:F ratio 1:1.6) underwent 47 direct laryngoscopies. The mean score for visualization of the glottis was 4.8 for the three-dimensional system compared to 4.0 for the two-dimensional system (P = .025), 4.7 vs. 3.8, respectively, (P = .019) for the subglottis, and 4.6 vs. 3.9, respectively (P = .031) for visualization of the proximal trachea. The mean score for visualization of the distal trachea was 3.0 vs. 3.7, respectively (P = .020). In a child with recurrent type 3 laryngotracheal cleft a residual tracheo-esophageal fistula could not be detected using the 2D system, but was immediately detected using the 3D system. CONCLUSIONS: Visualization of the glottis, subglottis and proximal trachea during direct laryngoscopy using a 3-dimensional endoscopic system was rated by the surgeons as being superior to the conventional 2-dimensional technique. Further outcome studies that will demonstrate the clinical advantage of the 3D technology are highly required. LEVEL OF EVIDENCE: 2b.

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.

Avoiding dacryocystorhinostomy in cases of epiphora caused by inferior meatus obstruction.

AIMS: To determine the role of inferior meatus pathologies as an underdiagnosed cause of epiphora. METHODS: This study was conducted in the oculoplastic institution of Tel Aviv medical center-a regional referral center. A retrospective review of files of patients presenting to the lacrimal clinic with nasolacrimal duct obstruction between October 2010 and September 2016. Cases in which a pathology of the inferior meatus was identified and treated are presented in this article. RESULTS: During this time frame, we preformed 186 endoscopic dacryocystorhinostomy surgeries. Out of those, eight patients (4.3%) were diagnosed and treated for pathology causing an obstruction of the inferior meatus. Seven of our patients were females; the mean age was 24 years. A wide range of pathologies were found: cysts, dacryoliths, membranes obstructing the inferior meatus, and concheal obstruction. All patients went through endoscopic treatment targeted at the cause of obstruction. During follow-up (average 35 months) only two patients remained symptomatic and were referred for an endonasal endoscopic dacryocystorhinostomy. CONCLUSIONS: Inferior meatus obstruction is an underdiagnosed cause of epiphora. Multiple pathologies may co-exist in the same patient. In select cases of NLDO, diagnosis and treatment can be done endoscopically, avoiding the need for dacryocystorhinostomy.

Juvenile Angiofibroma: Current Management Strategies.

Juvenile angiofibroma (JA) is a benign, highly vascular tumor which is diagnosed on the basis of clinical and imaging features. It has a characteristic pattern of spread commonly involving the pterygopalatine fossa and pterygoid base. The mainstay of treatment is surgery, while radiotherapy is rarely used for the treatment of recurrent lesion. Endoscopic endonasal surgery is currently the treatment of choice for small to intermediate size JAs, and is feasible even for advanced lesions; however, this should only be practiced in well-experienced centers.

Skull Base Reconstruction in the Pediatric Patient.

Introduction Pediatric skull base and craniofacial reconstruction presents a unique challenge since the potential benefits of therapy must be balanced against the cumulative impact of multimodality treatment on craniofacial growth, donor-site morbidity, and the potential for serious psychosocial issues. Objectives To suggest an algorithm for skull base reconstruction in children and adolescents after tumor resection. Materials and Methods Comprehensive literature review and summary of our experience. Results We advocate soft-tissue reconstruction as the primary technique, reserving bony flaps for definitive procedures in survivors who have reached skeletal maturity. Free soft-tissue transfer in microvascular technique is the mainstay for reconstruction of large, three-dimensional defects, involving more than one anatomic region of the skull base, as well as defects involving an irradiated field. However, to reduce total operative time, intraoperative blood loss, postoperative hospital stay, and donor-site morbidity, locoregional flaps are better be considered the flap of first choice for skull base reconstruction in children and adolescents, as long as the flap is large enough to cover the defect. Our "workhorse" for dural reconstruction is the double-layer fascia lata. Advances in endoscopic surgery, image guidance, alloplastic grafts, and biomaterials have increased the armamentarium for reconstruction of small and mid-sized defects. Conclusions Skull base reconstruction using locoregional flaps or free flaps may be safely performed in pediatrics. Although the general principles of skull base reconstruction are applicable to nearly all patients, the unique demands of skull base surgery in pediatrics merit special attention. Multidisciplinary care in experienced centers is of utmost importance.

The clinical behavior of sinonasal inverted papilloma with cellular dysplasia: case series and review of the literature.

The prognosis and recurrence rate of inverted papilloma (IP) with concomitant cellular dysplasia are not well-delineated. Demographic, clinical and imaging data of all patients who were surgically treated for sinonasal inverted papilloma (SNIP) in our center between 1996 and 2013 were reviewed. Data regarding the coexistence of dysplastic changes or malignancy within the resected tissues were also retrieved. After the exclusion of malignant cases and patients who were lost for follow-up, 92 patients were included in the study. Five patients had coexisting cellular dysplasia (4.7%), four of them had severe dysplasia and one had mild-to-moderate dysplasia. All four cases with severe dysplasia recurred, three were primarily treated endoscopically and one by external approach. Only the case with mild to moderate dysplasia which had been treated by subcranial approach did not recur. Patients with dysplasia had significantly higher recurrence rate than patients without dysplasia (80 vs. 14%, p = 0.019). This significant relation between histology and recurrence remained even after adjustment to tumor extent. The adjusted odd ratio of dysplasia (dysplasia vs. no dysplasia) is 9.7, p = 0.043. SNIP with dysplasia should be treated aggressively and followed closely. The histopathologic investigation of SNIP specimens should always note the presence of dysplasia and its severity. Further investigation on the clinical behavior of SNIP with dysplasia is needed. Multicenter studies are warranted due to the rarity of dysplastic SNIP.