Adverse events of biological therapy in chronic rhinosinusitis with nasal polyps: A systematic review.

The management of chronic rhinosinusitis with nasal polyps (CRSwNP) is challenging due to disease recurrence and adverse effects. Both surgical and medical treatment modalities impact the quality of patients' lives. Monoclonal antibody treatment has recently been used successfully in CRS with limited reported adverse events. We aimed to review the literature to shed more light on the safety and adverse events associated with the biological therapy of CRSwNP. A comprehensive systematic review was conducted on the safety of different biological treatments when used for managing CRSwNP. We have included 13 studies in the present systematic review, including 12 randomized controlled trials (RCTs) and one cross-sectional study. The total sample size for the included studies was 2282 patients. Six studies investigated the safety and adverse events of dupilumab; three investigated omalizumab, three investigated mepolizumab, and only one investigated reslizumab. Some studies have reported that adverse events were common with these types of drugs. However they were not specific and self-limited. Headaches, injection site reactions, and pharyngitis were the most common adverse events found among the reported adverse events. The Dupilumab trial reported pharyngitis in 225 patients (22.4 %) followed by erythema in 9.4 %, headache in 8.1 %, epistaxis in 5.1 %, and asthma in 1.7 % of patients. Trials which used omalizumab reported headaches, nasal pharyngitis, injection-site reactions to be the most common adverse events with estimated prevalence rates of 8.1 %, 5.9 %, and 5.2 %, respectively. Mepolizumab and reslizumab studies reported that 40 % of patients were complicated by nasal polyps/congestion/pharyngitis/infections, 14 had a headache (15.5 %), two developed asthma (2.2 %), and only one patient (1.1 %) had epistaxis as an adverse event. Although the literature's current investigations indicate the safety of the biologic treatment modalities, further studies are needed as some uncertainty among the trials have been reported.

Utilization of telemedicine in rhinologic practice during COVID-19 pandemic.

BACKGROUND: The only two preventive interventions available for COVID-19 have been social distancing and quarantine. These preventive measures challenge health care providers by causing cancelations of elective in-person outpatient clinic visits in many hospitals, particularly in otolaryngology clinics. OBJECTIVES: To assess the applicability and feasibility of telemedicine in rhinology cases with a study of outcomes to guide rhinologists on indications of in-office visits. Assessment of patient satisfaction with telemedicine in the rhinology clinic was also investigated. METHODS: A retrospective review of electronic charts of all adult patients (>18 years) who were scheduled in the rhinology clinics of King Abdulaziz University Hospital, Riyadh, Saudi Arabia, and received a phone call as a part of telemedicine care from April through June 2020. Demographics (including age and gender), diagnosis, plan of treatment, and status of the visit (either new or follow-up) were collected. In addition, we used a special questionnaire to measure the satisfaction rate among patients who received telemedicine services. RESULTS: A total of 339 patients were included. The mean age was 41 years with 60.2% males. Only 5 cases (1.48%) were asked to attend to the clinic. The vast majority of cases were given a follow-up (n = 311, 91.7%). The most common diagnosis among the follow-up cases was chronic rhinosinusitis with nasal polyposis (n = 130, 38.3%). The satisfaction telephone survey had a total of 41 respondents out of 80 cases selected randomly. Most respondents (83.3%) were satisfied with telemedicine services. CONCLUSION: We conclude that telemedicine proved its effectiveness in the efficient management and screening of rhinology cases during public health emergencies while providing sufficient protection for patients and medical practitioners. Telemedicine as a modality of care during the pandemic faced minor or no opposition given patients' understanding of the importance of social distancing.

STIMA: Submucosal Temporary Inferior Maxillary Antrostomy: A Modification of Conventional Antrostomy, A Retrospective Review.

Introduction: Maxillary sinus pathology is commonly approached through endoscopic middle meatal antrostomy (MMA). However, MMA does not provide full exposure to certain aspects of the maxillary sinus, such as alveolar, zygomatic, and prelacrimal recesses. In these hidden maxillary sinus niches, a combination approach with MMA is required for better exposure and access. In this article, we present a modification of inferior maxillary antrostomy (IMA) to allow for a temporary intraoperative window with no significant postoperative consequences. Objectives: (1) To describe our modification of IMA. (2) To report the outcome of maxillary sinus disease, postoperative complications, and flap condition. Methods: This is a retrospective chart review study. It was performed on 20 patients where submucosal temporary inferior maxillary antrostomy (STIMA) was indicated in the period from January 1, 2020, and July 1, 2023. All patients were assessed for their demographics, diagnosis, indication for STIMA, maxillary disease outcome, presence of postoperative complications, and flap condition. Result: Total of 18 patients fulfilled our inclusion/exclusion criteria; of them, 13 were males while the remaining were females. Mean age of patients was 33 years; most common diagnosis was chronic sinusitis. Status of maxillary sinus mucosa was healthy in all except 4 patients having polypoidal mucosa while flap condition was intact in all patients except 2 patients with pinpoint defects. Postoperative complications assessment demonstrated no neural, orbital, lacrimal, or dental complications in all patients. Conclusion: This retrospective chart review showed promising technique to address challenging maxillary lesions in difficult-to-access locations where combined approaches are necessary.

Prevalence of type 2 inflammation in patients with chronic rhinosinusitis with nasal polyps in Saudi Arabia.

Background: Chronic Rhinosinusitis (CRS) is a common condition causing a significant worldwide burden, affecting 5%-12% of the general population. CRS is classified into type 2 and non-type 2 disease based on endotype dominance. Type 2 inflammation is distinguished by the presence of IL-4, IL-5, and IL-13 cytokines, along with eosinophil and mast cell activation and recruitment. Evidence of type 2 inflammation is ascertained by tissue eosinophil count >10/high-power field (HPF) or serum eosinophil >250 cells/mcL or total immunoglobulin E (IgE) > 100 IU/ml. Objectives: To investigate the prevalence and characteristics of type 2 inflammation in patients who presented with nasal polyps and underwent Endoscopic Sinus Surgery (ESS) in Saudi Arabia. Design: A retrospective cross-sectional Study. Methods: This study was conducted among patients who presented with nasal polyps and underwent ESS at King Saud University Medical City (KSUMC) from 2015 to 2020. Patients with nasal/sinus diseases other than Chronic Rhinosinusitis with Nasal Polyps (CRSwNP) were excluded. Demographic data, olfaction status, and co-morbidities were collected, and radiological images were evaluated. Type 2-CRS was determined by meeting at least one of three predictor criteria (blood eosinophils ≥250 cells/mcL, tissue eosinophils ≥10/HPF, or total IgE levels ≥100 IU/ml). Blood parameters and histopathologic analysis were obtained for each patient. Results: Of the 381 patients included in the study, the prevalence of type 2-CRS, based on the EPOS2020 criteria, was 99.7% in our population. Among these patients, 47.5% had hyposmia, 38.8% had anosmia, and 13.6% had normal olfaction. The most prevalent co-morbidity was allergic rhinitis, followed by bronchial asthma. Conclusion: This study aimed to determine the prevalence of type 2 inflammation among patients Diagnosed with CRSwNP and underwent ESS in Saudi Arabia. The results showed a prevalence of 99.7%, indicating that almost all recorded patients with CRSwNP in our population had type 2 inflammation.

Suprasellar Meningioma Classification: Endoscopic Transnasal Perspective.

Objectives Midline suprasellar meningiomas include planum sphenoidale, tuberculum sellae, and diaphragma sellae meningiomas. Multiple classifications have been previously documented; however, they come with controversies and limitations, including those with surgical implications. The aim of this study was to classify suprasellar meningiomas based on their behavior toward the underlying bone and neurovascular structures. Methods Patients with newly diagnosed suprasellar meningiomas that underwent extended endoscopic transnasal approach between 2015 and 2021 were included in this study. The following parameters were evaluated: chiasmatic sulcus length, location of the optic chiasm and nerves, optic canal involvement, and vascular displacement. Results We identified 40 cases of midline suprasellar meningiomas, 1 diaphragma sellae meningioma (type A), 10 tuberculum sellae meningiomas (type B), 9 chiasmatic sulcus meningiomas (type C), and 10 planum sphenoidale meningiomas (type D). Asymmetrical visual complaints were most common in chiasmatic sulcus meningiomas, followed by tuberculum sellae meningiomas (66 and 50%, respectively). Chiasmatic sulcus meningiomas showed increased separation between the optic chiasm and the A1/A2 complex (8.9 mm) compared with tuberculum sellae (2.7 mm) and planum sphenoidale (1.9 mm) meningiomas. Compared with other types, increased chiasmatic sulcus length was observed in chiasmatic sulcus meningiomas. Conclusion Preoperative evaluation of bone involvement and tumor relation to neurovascular structures can be used to classify suprasellar meningiomas. Chiasmatic sulcus meningioma is a distinct subtype of suprasellar meningiomas. Its unique behavior toward nearby neurovascular structures could be of surgical value during tumor resection.

Outcomes of Endoscopic Sinus Surgery for Chronic Rhinosinusitis With Nasal Polyposis and Risk Factors of Recurrence in a Tertiary Care Teaching Hospital.

Background: Endoscopic sinus surgery (ESS) has become the gold standard for treating patients with chronic rhinosinusitis (CRS) refractory to medical therapy. It is considered a relatively safe and effective procedure in all age groups, with overall success rates ranging from 76% to 97.5%. However, failure of primary endoscopic sinus surgery (PESS) occurs at a rate ranging from 2% to 24%. Patients who are still symptomatic after PESS and optimal medical therapy are candidates for revision endoscopic sinus surgery (RESS). Objectives: to study the outcomes of ESS and assess the risk factors of recurrence of nasal polyps, as well as to compare the outcomes of PESS and RESS at a tertiary care teaching hospital. Design: A retrospective cross-sectional study. Methods: This study is conducted on patients with CRS with nasal polyps (CRSwNP) who underwent ESS at King Saud University Medical City (KSUMC) between May 2015 and December 2021. During this period, ESS was performed 470 times for CRSwNP. The Sinonasal Outcome Test 22 (SNOT-22) questionnaire, the Lund-Kennedy (LK) score, the Lund-MacKay (LM) score, and the polyp grading system were used to evaluate subjective and objective outcomes. They were scored preoperatively and from 6 to 12 months postoperatively. Results: Out of the 470 endoscopic sinus surgeries, 321 (68.3%) were PESS and 149 (31.7%) were RESS. Asthma, aspirin sensitivity, and Samter's triad were observed more in the RESS group. The LK and LM scores were significantly different between primary and revision sinus surgeries, revealing that PESS patients had better postoperative LK and LM scores. The RESS patients had significantly worse postoperative SNOT-22 scores compared to PESS patients. Conclusion: Lund-MacKay, Lund-Kennedy, and SNOT-22 scores improved after ESS for both primary and revision ESS patients, with better outcomes observed after PESS compared to RESS. The presence of asthma, aspirin sensitivity, Samter's Triad, high-grade nasal polyps, and older age were identified as risk factors for CRSwNP recurrence, which may require RESS.

Bilateral maxillary silent sinus syndrome: A case report and literature review.

Silent sinus syndrome refers to a spontaneous enophthalmos caused by maxillary sinus collapse without any symptomatic sinonasal illnesses. Its prevalence is almost entirely unilateral. The authors report a patient with a bilateral silent sinus syndrome managed successfully by middle meatal antrostomies. This case brings attention to recognizing bilateral silent sinus syndrome. Because of its bilateral involvement, the facial disfigurement might be recognized late due to the symmetrical presentation. This article highlights the pathophysiology and reports the detailed course of such a rare disease. The balloon dilatation is promising as a newly described treatment modality in a patient with silent sinus syndrome, although more long-term data on its outcome is needed.

Loss of Vision Outcome for Allergic Fungal Sinusitis: Case Report and Literature Review.

Visual loss is a rare manifestation of allergic fungal rhinosinusitis (AFRS). We report a case of an adult male who was diagnosed with AFRS and who presented during the COVID-19 pandemic lockdown with sudden-onset complete vision loss and a lack of recovery after surgical and medical management. We reviewed the literature on reported cases of AFRS complicated by visual loss to identify factors associated with visual outcomes. We found 50 patients who were diagnosed with acute visual loss due to AFRS, with an average age of 28 ± 14 years. Complete and partial recovery after surgical intervention were reported in 17 and 10 cases, respectively. However, the absence of vision improvement was reported in 14 of the cases. Early diagnosis and prompt intervention can return vision back to normal. However, delayed presentation, complete loss of vision, and acute onset of visual loss are associated with worse outcomes.

Temporary Submucosal Inferior Maxillary Antrostomy: A Modification of the Inferior Antrostomy.

Complete removal of maxillary sinus pathology can be challenging in specific locations. In the past, the Caldwell-Luc procedure was used for maxillary sinus disease. Currently, the endoscopic middle meatal antrostomy (EMMA) approach is used. However, it can often be difficult to reach certain locations of lesions by EMMA alone, requiring an endoscopic inferior meatal antrostomy (EIMA), which has been reported in the literature to have numerous complications. Furthermore, multiple techniques have been suggested for a combined bi-meatal approach to remove such lesions. We present a case of a 17-year-old with a challenging antrochoanal polyp (ACP) location requiring EIMA. The patient underwent our modified technique of submucosal inferior antrostomy with mucosal flap with no observed intra-operative and post-operative complications. Maxillary sinus pathology can be challenging due to limited access to specific regions. In this case report, we present a novel technique to achieve a temporary inferior antrostomy through a minimally invasive approach with a promising post-operative course.

Abducens Nerve Neuropraxia due to Acute Bacterial Rhinosinusitis: Case Report and Literature Review.

Background: Acute bacterial rhinosinusitis (ABRS) is a common infection of the paranasal sinuses that can lead to complications such as orbital and intracranial extension. The abducens nerve course is adjacent to the sphenoid sinus. Diplopia is rarely the initial presentation of sphenoid sinus pathology. In this article, we present the case of a middle-aged male who presented with diplopia and abducens nerve palsy secondary to ABRS, and we conducted a literature review in search of similar cases. Case Presentation. A 52-year-old male presented with diplopia secondary to ABRS. Imaging revealed the complete opacification of the bilateral sphenoid and frontal sinuses, with the extension of the inflammatory process to the optic nerve and cavernous sinus. The patient underwent a surgical intervention, which revealed a pyocele collection in the opticocarotid recess inside the sphenoid sinuses. After the surgery, the patient received antibiotics and reported a complete recovery. Conclusions: Acute bacterial rhinosinusitis can present with atypical symptoms and lead to serious complications, such as abducens nerve palsy. Early diagnosis, appropriate management, and timely referral to a multidisciplinary team are crucial to preventing residual nerve damage and ensuring favorable outcomes.

Evaluation of Chronic Rhinosinusitis Symptoms' Severity Following COVID-19 Infection: A Retrospective Analysis.

Objectives This study aims to compare the severity of chronic rhinosinusitis (CRS) symptoms pre- and post-COVID-19 infection and estimate the impact of the COVID-19 pandemic on the use of intranasal corticosteroids (ICS) among adult CRS patients. Methods This was an observational retrospective cohort study conducted at King Abdulaziz University Hospital, Riyadh, Saudi Arabia, between July 2022 and October 2022. Adult CRS patients with sino-nasal outcomes test-22 (SNOT-22) scores documented prior to March 2020, marking the occurrence of Saudi Arabia's initial reported case of COVID-19, were requested to complete the SNOT-22 questionnaire following COVID-19 infection. A comparison was subsequently made between the two scores obtained. Results The study enrolled a total of 33 patients, with 16 assigned to the control group and 17 with a history of COVID-19 infection. The mean age of the patients was 43 years, and the majority (52%) were males. Statistical analysis did not reveal any statistically significant differences in the total SNOT-22 scores or domain-level scores between the two groups. Furthermore, the use of ICS during the COVID-19 pandemic did not show any significant associations, except for patients with asthma, where 80% of them used ICS during the pandemic (p=0.0073). Conclusion There was no statistically significant disparity observed in the SNOT-22 scores between patients who tested positive for COVID-19 and those who did not. The use of corticosteroids during the COVID-19 pandemic was found to be more prevalent in this study compared to previous studies conducted before the pandemic, particularly among patients with asthma. The use of ICS during the pandemic was not associated with the presence of polyps, functional endoscopic sinus surgery (FESS), allergic rhinitis, or eczema.

STIMA: Submucosal Temporary Inferior Maxillary Antrostomy: A Cadaveric Controlled Study of a Modification of the Conventional Antrostomy.

Introduction: Inferior meatal antrostomy (IMA) is a safe and easy approach to the maxillary sinus. However, studies have shown disadvantages of conventional IMA, such as disruption of mucociliary transport and injury of the nasolacrimal duct (NLD). Endoscopic middle meatal antrostomy (MMA) has become the standard of care for addressing various maxillary pathologies. It is more functional and physiological but offers limited exposure to certain areas of the maxillary sinus, such as the prelacrimal recess, alveolar recess, and zygomatic recess. We proposed submucosal temporary inferior maxillary antrostomy (STIMA) to improve visualization and accessibility to such difficult-to-access locations. Objectives: To describe our proposed modification, to compare the degree of visualization and ease of accessibility between MMA and STIMA. Methods: This is a descriptive cadaveric study. It was performed on 4 fresh frozen human cadavers, and 8 maxillary sinuses were used to achieve the study's objectives. Different angled rigid nasal endoscopes and suction tubes were used to score the degree of visualization and ease of accessibility between the MMA and STIMA. Result: We demonstrated the superiority of the STIMA over the MMA in the degree of visualization and ease of accessibility in these difficult-to-access locations (P-value was significant, <.05). We did not encounter orbital injury or injury to the NLD in our specimens. Conclusion: STIMA is a relatively easy and safe modification of conventional IMA. It improves the degree of visualization and ease of accessibility to difficult-to-access maxillary sinus locations without the potential complications of conventional IMA.

Impact of Concurrent Chronic Rhinosinusitis on Complication Rates after Endonasal Endoscopic Skull Base Surgery: A Single-Center Experience.

Objectives Preoperative planning of endoscopic skull base surgery (ESBS) is essential. The safety of performing surgery before managing sinus pathologies including concurrent chronic rhinosinusitis (CRS) in patients undergoing ESBS has been questioned. The current study aimed to evaluate and compare the complication rates between patients with and without CRS undergoing ESBS. Design This is a retrospective study. Setting Present study was conducted at tertiary referral center. Participants We included all patients who underwent ESBS between March 2015 and March 2021. However, patients who had surgical revision for remnant tumor, primary sinonasal tumor excision, and cerebrospinal fluid (CSF) leakage repair were excluded. The presence of concurrent CRS was determined according to the European Position Paper on Rhinosinusitis and Nasal Polyps 2020 (EPOS 2020) criteria by reviewing electronic charts about the preoperative clinical assessment and CT scan images of the paranasal sinuses. Then, the incidence rates of postoperative meningitis, CSF leakage, and surgical site infection were compared between patients with and without concurrent CRS undergoing ESBS. Main Outcome Measures Postoperative complication rates in patients underwent ESBS with and without CRS. Results From a total of 130 ESBS cases, 99 patients were included in this study. Among them, 24 had concurrent CRS. One patient presented with postoperative meningitis, one with CSF leakage, and two with surgical site infections. The incidence rate of postoperative meningitis, CSF leakage, and surgical site infection did not significantly differ between patients with and without concurrent CRS. Conclusion Concurrent CRS is not a contraindication for ESBS. Moreover, simultaneous endoscopic sinus surgery can safely be performed without additional morbidity in ESBS.

Classification of Endoscopic Transnasal Lateral Skull Base Approaches: Anatomical Study.

OBJECTIVE: Endoscopic transnasal approaches (ETAs) to the ventrolateral skull base are commonly classified according to coronal planes or anatomical structures. Our goal is to simplify the description of the ETA to lateral skull base regions in a sequential dissection with correlation to computed tomography, helping in preoperative planning and efficient surgical exposure, and exposing the surgical anatomy limitations. METHODS: Five freshly injected cadaver heads were dissected using an extended ETA to the lateral skull base. Each specimen underwent a high-resolution computed tomography scan. A classification of the lateral skull base based on well-defined zones was proposed. RESULTS: We divided the lateral target into four different zones, in a craniocaudal orientation: zone 1 is the space lying between the orbital floor superior and the level of the sellar floor inferior, zone 2 is on the coronal plane, located between the level of the sellar floor and the vidian canal, zone 3 is the area lateral to the anterior limb of the petro-occipital fissure, located between the vidian canal and the carotid canal, and zone 4 is the space located between the carotid canal and the extracranial opening of the hypoglossal canal, lateral to the anterior part of the posterior limb of petro-occipital fissure. CONCLUSIONS: Multiple previous works have described and classified the coronal plane and its lateral extensions. Our classification system for the proposed lateral zones enables preoperative planning to select a suitable approach. The craniocaudal orientation facilitates the understanding of surgical corridors and tailored exposure.

Complications of endoscopic sinus surgery for chronic rhinosinusitis in a tertiary care teaching hospital in Saudi Arabia.

OBJECTIVES: To aimed to determine the incidence of complications of endoscopic sinus surgery (ESS) and to investigate the factors associated with the occurrence of complications. METHODS: In this retrospective study, we reviewed the medical records of all patients who had undergone ESS at King Saud University Medical City (KSUMC) between January 2015 and March 2022. Patients who underwent ESS for complicated acute sinusitis, sinonasal malignancy, and cerebrospinal fluid leak repair, and those who underwent extended ESS for indications other than chronic rhinosinusitis were excluded. This study was approved by the KSUMC Institutional Review Board. RESULTS: We included 1395 patients, 3 of whom had major complications and 28 had minor complications, resulting in an overall major complication rate of 0.2% and a minor complication rate of 2%. The most common major complication was orbital hematoma, and the most common minor complication was synechia. Moreover, the duration of surgery and laterality increased the risk of complications, whereas the use of image guidance had no effect. CONCLUSION: The ESS is a safe procedure. The operative start time and laterality were associated with an increased risk of complications and warrant further investigation.

Demographic and clinical profile of patients with chronic rhinosinusitis in Saudi Arabia.

OBJECTIVES: To determine the clinical features of patients with chronic rhinosinusitis at a tertiary hospital in Riyadh, Saudi Arabia. METHODS: A cross-sectional study was carried out at King Abdulaziz University Hospital, Riyadh, Saudi Arabia. We enrolled 660 male and female participants with medical records indicating a history of chronic rhinosinusitis between 2021 and 2022. Quantitative and descriptive analyses of age, gender, nationality, presence of polyps, aspirin sensitivity, presence of urticaria, asthma, and allergies were performed. RESULTS: Of the 660 enrolled patients, 60% (n=396) were male and 40% (n=264) were female. Additionally, 67.7% (447) had nasal polyps, 32% had a history of asthma, 10% had hypersensitivity to aspirin, 1.4% reported a history of urticaria, 9.7% reported allergies to medications, 7.9% reported food allergies, 26% reported multiple allergies, and 1.8% reported environmental allergies. CONCLUSION: Our study revealed the following: Samter's triad was present in 6.9% of participants with chronic rhinosinusitis; the greatest prevalence of chronic rhinosinusitis with nasal polyps was observed among those older than 50 years. The prevalence of urticaria was not significantly different among groups; a higher rate of environmental allergies was observed among those with CRSwNP than among those without nasal polyps; and a higher prevalence of aspirin hypersensitivity was observed among those with CRSwNP than among non-polyps group.

Impact of Preoperative Steroids Administration on Endoscopic Sinus Surgery: Systematic Review of Literature, and a Survey in Saudi Arabia.

There is limited knowledge in the literature and lack of clear protocols among practitioners regarding preoperative steroids administration for patients undergoing endoscopic sinus surgery (ESS). This study aimed to identify the practice patterns of rhinologists in Saudi Arabia as well as systematically review all health-related evidence regarding the use of preoperative steroids for ESS. A previously used questionnaire was modified and distributed in Saudi Arabia among rhinologists who finished their residency training. It entailed questions about their qualifications and preoperative steroids use, preferred regimen, and possible benefits. Also, a systematic literature review using four major databases was conducted to build a scoping view of the current evidence. A total of 94 subjects responded to the mailed survey. Of them, 72(76.6%) used preoperative steroids; 40 subjects believed that there is a strong supporting evidence while 32 reported that there is no solid evidence. The commonest indication was chronic rhinosinusitis with nasal polyp followed by allergic fungal rhinosinusitis. More than half of subjects (54.2%) preferred medium-dose prednisone (30-40 mg/day). A considerable number believed that steroids decreased surgical bleeding (n = 57, 79.2%), improved surgical field visualization (77.8%), decreased surgical time (77.8%), and decreased mucosal inflammation (61.1%). Thirteen studies including 1028 patients were eligible for the systematic review. Only three studies reported a statistically significant effect of steroids in reducing intraoperative hemorrhage, while only two studies revealed that steroids significantly improved surgical field quality. In two studies, steroids showed a significant effect in reducing eosinophil infiltration. There is a major number of rhinology experts using preoperative steroids for patients undergoing ESS but there is a wide variation among their practice patterns. The current potential advantages of steroids need to be supported by further large randomized clinical trials to establish clear guidelines.

Alveolar Soft-Part Sarcoma in Olfactory Cleft: A Case Report and Clinicopathological Review.

Sinonasal alveolar soft-part sarcoma (ASPS) is a rare malignant disease that comprises 0.4% to 1.2% of all soft-tissue sarcomas. Alveolar soft-part sarcoma is usually difficult to diagnose because it has many clinical and pathological mimickers. In this case study, ASPS occurred in the olfactory cleft, representing the second case in this location in the literature. This article presents the clinical presentation, radiologic, and histopathological case, and reviews the literature regarding the differentials.

Drug-Induced Rhinitis: Narrative Review.

OBJECTIVES: Rhinitis, one of the most common inflammatory conditions of the nasal mucosa, is known to affect a large proportion of people worldwide. It is generally classified into allergic and non-allergic types and both are associated with several unpleasant symptoms. Several medications prescribed for different medical conditions can cause unpleasant rhinitis as an adverse effect, which is known as drug-induced non-allergic rhinitis. The aims of this article were to review the literature to identify drugs that could induce rhinitis, prevalence of drug-induced rhinitis, and the associated pathogenic mechanisms if known. METHODS: Literature search screening for eligible papers published up to December 31st, 2021, in Medline (via PubMed) and Embase was conducted. The search included the following combination of keywords and terms: rhinitis, sneezing, congestion, allergic, non-allergic, rhinorrhea, vasomotor, medication, drug-induced. RESULTS: The review findings suggest that 12 subtypes of drugs potentially could induce rhinitis. Based on their mechanisms of action, the pathogenic causes for the induction of rhinitis have been recognized for some drugs, while others remain unknown. CONCLUSION: Awareness of the list of drugs that reportedly induce non-allergic nasal symptoms, along with taking the patient's medication history, is important in the diagnosis of rhinitis.

Extent of Nasal Irrigation in Non-operated Sinuses: A Cadaveric Trial.

BACKGROUND: Nasal irrigation is among the most widely used treatment modalities for sinonasal diseases. The extent of irrigation is well studied in operated sinuses but not for non-operated sinuses. Moreover, the preferred head positioning during irrigation is not known. Herein, we studied the extent of nasal irrigation in cadaveric heads with non-operated sinuses. METHODS: Nine cadaveric heads were used. Normal saline solution mixed with radiological contrast material was used to irrigate the nasal cavities with the heads in 2 different positions: standing-leaning-forward (SLF) and Head-down forward (HDF). After each irrigation, computed tomography images of the head were acquired. The extent of irrigation was assessed for each subunit of the sinonasal cavity. RESULTS: Irrigation was performed twice on a total of 18 sides, each time in 1 position. Nine subunits were evaluated: inferior, middle, and superior meati; the olfactory cleft; and the frontal, maxillary, anterior, and posterior ethmoid and sphenoid sinuses. The extent of irrigation was significantly better in the HDF position for the olfactory cleft (100% vs 33%), P-value=.001, frontal sinus (33% vs 11%), P-value=.002, maxillary sinus (78% vs 17%), P-value=.001, and anterior ethmoid sinus (89% vs 17%), P-value=.001. There was no significant difference in the extent of irrigation between the 2 positions for the other evaluated subunits. The overall extent of irrigation was 70.37% of the subunits in HDF position and 45.06% of the subunits for SLF position, P-value= .001. CONCLUSIONS: Nasal irrigation reached the cavities of non-operated paranasal sinuses. However, while the extent of irrigation was limited in the SLF, it was well achieved in the HDF position. Studies on the clinical efficacy of irrigation in this position are recommended.