Alexander G. Chiu

Objectives: First-line treatment of chronic rhinosinusitis includes topical corticosteroids aimed at decreasing inflammation of sinonasal mucosa. No guidelines exist regarding the effect of head position during administration of corticosteroids. We hypothesize certain positions enhance delivery to the paranasal sinuses, with further improvement in delivery after sinus surgery. Methods: A systematic review of the literature was conducted using Medline Ovid, Embase, Scopus, and Cochrane databases. All studies evaluating intranasal medications administered in 2 or more head positions were included. Study population, head position(s), method/volume of delivery, and outcome metrics were recorded. Results: Twenty-four studies compared head positions and their role in distribution of intranasal medication. Of 12 papers studying surgically naive subjects, 6 found improvement in delivery to specific sinonasal regions (middle meatus; lateral, superior, or posterior nasal cavity) and/or symptomatic improvement, in the lying head back (LHB) or head down and forward (HDF) positions, but only 3 reached statistical significance. Of 12 papers studying surgically altered patients, 10 found delivery improved in the HDF, LHB, and head forward 45° or 90° positions. Of 5 studies of extended frontal sinus procedures (Draf IIb/III), a majority found distribution to the frontal sinus improved with the head forward 90° position. Patients found the HDF position most uncomfortable. Conclusions: Studies found no statistically significant difference in distribution to unoperated sinuses among different head positions. A minority of studies supported the use of the LHB and HDF positions. This suggests that in surgically naive patients, intranasal corticosteroid delivery to sinonasal regions and/or symptomatic improvement may be best achieved with the sinuses positioned inferior to the delivery device. Surgery improved distribution to the paranasal sinuses regardless of head position, although tilting the head forward 90° was particularly effective in delivery to the frontal sinus after extended frontal sinus procedures.

Background: Intrathecal fluorescein (IF) has become a common tool for localization of cerebrospinal fluid (CSF) leak, but despite frequent use, IF lacks Food and Drug Administration approval. The diagnostic ability of high-resolution computed tomography (HRCT) has increased over several decades. Subspecialized rhinology training within otolaryngology has, similarly, allowed for dedicated skull base surgeons to become more adept at CSF leak localization. Objectives: To evaluate the utility of HRCT and IF in CSF leak localization. To identify certain patient populations in which IF has added utility. To analyze the ability of fellowship-trained neuroradiologist and rhinologist to localize CSF leak sites. Methods: Data were collected from a single, tertiary care academic institution. Patients admitted for CSF leak between 2003 and 2016 were included. Diagnostic yield of preoperative imaging and IF for identification of leak site was analyzed. Fellowship-trained neuroradiologist and rhinologist performed retrospective review of CT imaging and identified CSF leak sites. Results: One hundred and two patients underwent CSF leak repair. Skull base defects were preoperatively localized to exact sinus on imaging report in 67% of patients. Preoperative imaging stratified by CT slice thickness of 0.625 mm identified leak site in 88.9% of cases. Blinded retrospective review by a neuroradiologist and rhinologist was able to localize the CSF leak to the correct or adjacent sinus in >80% of cases. IF was useful for intraoperative localization in 73% of cases. When preoperative imaging failed at leak site localization, IF was able to correctly identify leak site in 75% of cases. Conclusions: The diagnostic yield of IF and CT imaging was equivalent, with each modality localizing leak site approximately two-thirds of the time. CT imaging with 0.625 mm slice thickness proved more efficacious in identification of skull base defects. IF demonstrated increased utility in instances where preoperative imaging has failed at leak site identification.

Sinonasal malignancies are rare and heterogeneous cancers located adjacent to critical neurovascular structures. Proximity to the orbit, brain, cranial nerves, and carotid arteries make surgical resection technically challenging and potentially morbid. The gold standard surgical procedure for these cancers has traditionally been the open craniofacial resection. Endoscopic endonasal approaches emerged in the last two decades as a viable alternative for carefully selected patients. The rarity and heterogeneity of the cancers precludes randomized controlled trials. Evidence for surgical approaches is based on case series and multi‐analyses. Current evidence demonstrates that endoscopic approaches do not compromise survival and have lower complication rates. This article provides an update of the current literature examining outcomes for the endoscopic treatment of sinonasal malignancies.

Introduction: Sinonasal Undifferentiated Carcinoma (SNUC) is an aggressive neoplasm, with conflicting existing literature regarding prognosis and treatment due to the rarity of disease. Characterization of optimal SNUC management is necessary for improved outcomes. Methods: Patients with pathologically confirmed SNUC treated within the 15-year period from 1991 to 2015 at the Hospital of the University of Pennsylvania were identified, and records were obtained and evaluated for several demographic characteristics. Overall survival from diagnosis was the primary endpoint, while disease recurrence and presence of distant metastases were secondary endpoints of the study. Results: Twenty-seven patients with established SNUC were included in this cohort, with a median age of 55 years. 85% of patients were surgically treated, and 85% of patients presented with stage IV disease. 2-year overall survival was 64% and 5-year overall survival was 40%. 96% of patients received both chemotherapy and radiation as adjuvant treatment. Stage IVC disease, distant metastases, and disease recurrence all significantly decreased patient survival (p < 0.01). Conclusion: This is an analysis of a single-institution SNUC cohort, consisting of 27 SNUC patients treated within a 15-year period. The majority of patients at this institution presented with clinically advanced disease, and most were managed with a multimodality approach of surgical resection, chemotherapy, and radiation. Extent of disease at presentation and progression of disease following treatment are poor prognostic signs and may merit a more aggressive approach, while early detection and treatment appear to improve survival and decrease patient morbidity.

Objectives/Hypothesis Surgery and postoperative radiation therapy are commonly used in the treatment of advanced sinonasal cancer. However, post-treatment radiation changes to the brain often mimic radiologic findings suggestive of tumor recurrence, leading to potential unnecessary intracranial biopsies. The objective of this study was to determine clinical factors that predict signs of tumor recurrence versus radiation necrosis in post-therapy sinonasal malignancies with intracranial extension. Study Design Retrospective study. Methods Twenty-six patients with sinonasal malignancy with intracranial extension underwent surgery and radiation ± chemotherapy between 2010 and 2014 at the University of Arizona. We analyzed sinonasal cancer type, stage, total radiation dosimetry, time until imaging changes, surgical pathology, associated imaging, and patient demographics. Results Thirteen of 26 patients had postoperative imaging changes seen on surveillance magnetic resonance imaging (MRI). Five were deemed to have tumor recurrence due to new metastasis seen on positron emission tomography/computed tomography scan. Four patients were observed with serial imaging that confirmed pseudoprogression. In four patients, there was sufficient concern due to persistent MRI changes, which prompted surgical biopsy, and only one of them was positive for tumor recurrence. Factors that favored tumor recurrence included faster onset of imaging changes on MRI (55 vs. 186 days, P < .05). Conclusions Intracranial tumor recurrence can be difficult to distinguish between radiation necrosis in sinonasal cancers treated with surgery and postoperative radiation ± chemotherapy. Patients with sub–total resection and rapid onset of MRI changes in postsurveillance scans are more likely to have tumor recurrence versus radiation necrosis. Future imaging techniques or tests that investigate tumor biomarkers are necessary to prevent unnecessary biopsies. Level of Evidence 4 Laryngoscope, 126:2445–2450, 2016

Background: Patients with diabetes mellitus (DM) are known to be prone to infection. However, the association between diabetes and chronic rhinosinusitis (CRS) has not been well studied. We sought to determine the effects of DM on CRS culture results and quality of life (QOL) after functional endoscopic sinus surgery (FESS).Methods: We conducted a retrospective cohort study. Adult CRS patients undergoing FESS were recruited from October 1, 2007 to December 31, 2011. Patient demographics, comorbidities, medication use, and Lund‐Mackay CT scores were collected prior to FESS. Intraoperative culture was obtained. Preoperative and 1‐month, 3‐month, and 6‐month postoperative QOL was measured by scores on the 22‐item Sinonasal Outcome Test (SNOT‐22). A mixed effects model was performed for analysis.Results: Among the 376 CRS patients included, 19 patients (5.05%) had DM. Compared to non‐DM patients, DM patients were significantly more likely to have Pseudomonas aeruginosa (26.32% vs 7.56%; p = 0.004) and Gram‐negative rods (26.32% vs 8.96%; p = 0.013), but there was no significant difference in the prevalence of Staphylococcus aureus; DM patients were also significantly more likely to have nasal polyps and gastroesophageal reflux disease. Additionally, DM patients had significantly less improvement of postoperative SNOT‐22 scores from baseline to 6‐month follow‐up than non‐DM patients (adjusted mean = 11.14, 95% CI (0.14, 22.15), p = 0.047) after adjusting for all the other risk factors for CRS.Conclusion: DM patients may be prone to Gram‐negative bacterial sinus infections, and have significantly worse short‐term postoperative QOL. Special postoperative care may need to be considered in CRS patients with DM.