Amin Javer

Transorbital endoscopic surgery is an increasingly adopted minimally invasive skull base approach in neurosurgical and otolaryngological practice. This review quantifies reported intraoperative and postoperative complications and evaluates the current evidence regarding its risks and limitations. A systematic review was conducted in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. PubMed, MEDLINE, and Embase were searched via Ovid, with additional gray literature screening. Studies reporting clinical outcomes of endoscopic transorbital surgery with postoperative follow-up were included. Two independent reviewers performed study selection and data extraction. Complications were categorized by anatomical location and duration (temporary vs. permanent). Risk of bias was assessed using the Joanna Briggs Institute appraisal tools. Thirty-four studies comprising 598 patients were included. The most common indications were spheno-orbital meningiomas, cerebrospinal fluid leaks, and orbital tumors. The superior eyelid crease approach was most frequently used. The most common orbital complications were transient periorbital edema (9.7%) and diplopia (5.2%). Sensory disturbances in the trigeminal distribution were the most frequent neurological complication (12%). Cerebrospinal fluid leak occurred in 2% of cases, typically managed conservatively or repaired intraoperatively. Major neurological and vascular complications were rare, including two ischemic strokes and two internal carotid artery injuries, without reported permanent deficits. Mortality was low and largely attributable to underlying disease. Endoscopic transorbital surgery demonstrates a favorable safety profile, with most complications being minor and self-limiting. It represents a minimally invasive alternative or adjunct to traditional skull base approaches in selected patients. Standardized reporting and prospective comparative studies are needed to define long-term outcomes and optimal indications.

Background: In-office endoscopic sinonasal procedures under local anesthesia are gaining popularity for managing chronic rhinosinusitis (CRS), reducing wait times and costs. However, concerns remain regarding safety and efficacy. Objective: To investigate the safety and efficacy of in-office endoscopic sinonasal procedures up to one year postoperatively. Methods: A retrospective review was conducted of adult patients (≥18 years) with CRS who underwent an in-office endoscopic sinonasal procedure under local anesthesia between January 2020 and December 2023. Patients were excluded if they were diagnosed with a sinonasal tumour. Safety was assessed using adverse events and complication rates, while efficacy was assessed with endoscopic visualization. Results: A total of 165 patients were included. Intraoperative complications were rare, with two (1.2%) occurring in the CRS cohort. Four episodes of postoperative bleeding (2.5%) occurred, with two (1.3%) emergency department visits and one (0.6%) hospital admission. The median Modified Lund-Kennedy score (n=89) decreased from 4/12 to 3/12 at three (p = 0.0004) and six (p = 0.03) months postoperatively, and to 2/12 at twelve months postoperatively (p = 0.003). Conclusion: In-office endoscopic sinonasal procedures are a safe, effective, and well-tolerated treatment alternative for appropriate patients with CRS. This represents the largest Canadian study to date evaluating in-office endoscopic sinonasal procedures for CRS.

Objective: To assess whether patients of advanced age with chronic rhinosinusitis (CRS) experience comparable symptom improvement and disease control following endoscopic sinus surgery (ESS) compared to younger patients. Data Sources: Systematic searches were performed across PubMed, Embase, Web of Science, Scopus, and CENTRAL to May 2024. Review Methods: Following PRISMA guidelines, we included comparative studies with age‐stratified cohorts reporting outcomes for CRS patients undergoing ESS. The primary outcome was symptom improvement measured by the 22‐item Sinonasal Outcome Test (SNOT‐22). Secondary outcomes were disease recurrence and revision rates. Meta‐regression examined the influence of sex, preoperative symptom severity, nasal polyps, and prior ESS. Results: Across the included studies, data from 3161 patients were analyzed. Advanced‐age patients demonstrated significantly less SNOT‐22 improvement than younger counterparts (SMD −0.36; 95% confidence interval [CI], −0.61 to −0.10; P = .01). Nevertheless, recurrence and revision rates were lower in the advanced‐age group—12% and 3%, respectively—corresponding to a 50% reduction in combined risk (RR 0.50; 95% CI, 0.33‐0.75; P < .001). Meta‐regression identified male sex as a predictor of greater symptom improvement in advanced‐age patients ( β = 0.06, P = .03), whereas prior ESS was associated with diminished improvement ( β = −0.05, P < .01). Conclusion: Patients of advanced age may experience less pronounced symptomatic improvement but lower recurrence and revision rates after ESS. These differences should be interpreted with caution, as they may reflect both surgical outcomes and other factors such as comorbidities or reoperation thresholds. Age alone should not preclude ESS, which remains an effective option when tailored to individual patient characteristics.

Background: Complications from in-office inferior turbinate (IT) and septal swell body coblation typically include pain, congestion, and bleeding. However, rare cases of cranial nerve palsies from local anesthetic infiltration can occur. We present a rare case of an oculomotor nerve palsy and palsies of the ophthalmic (V1) and maxillary (V2) branches of the trigeminal nerve following intranasal local anesthetic infiltration prior to coblation, a complication not previously documented in the literature. Awareness of such rare and transient complications can help surgeons and clinicians avoid unnecessary interventions and better counsel patients. Case Description: A 75-year-old female with a one-year history of recalcitrant bilateral nasal obstruction underwent an in-office primary bilateral coblation of the ITs and septal swell bodies. Four percent lidocaine-soaked neuropatties were applied over the ITs and septal swell bodies, followed by infiltration with 0.25% bupivacaine hydrochloride with 1:200,000 epinephrine. Shortly after infiltration, the patient developed left-sided ptosis and was unable to adduct the left eye, causing diplopia. Additionally, the patient reported paresthesia in the V1 and V2 dermatomes. All symptoms resolved within 15 minutes. At the 6-week post-procedure visit, there was no sustained diplopia, left eye ptosis, or facial paresthesia. These symptoms also remained absent at the six-month post-procedure visit. Conclusions: Although relatively low-risk, surgeons should be aware of potential cranial nerve complications associated with intranasal anesthetic administration. Recognizing the benign and reversible nature of such presentations may help avoid unnecessary diagnostic workups, reduce patient distress, and reinforce best practices such as aspiration prior to infiltration and slow injection techniques.

Allergic fungal rhinosinusitis (AFRS) is a unique endotype of chronic rhinosinusitis with nasal polyps (CRSwNP). Despite high recurrence rates and often more severe presenting signs compared with other subtypes of CRSwNP, research dedicated to AFRS has been lacking. Diagnostic criteria are outdated, the mechanistic relationship of AFRS to other associated diseases is unclear, and the pathophysiology of disease and risk factors for recurrence have not been well studied. In December 2023, a multidisciplinary group of rhinologists, otolaryngologists, pulmonologists, allergists, immunologists, scientists, and infectious disease experts met at the National Institute of Health to discuss unmet needs for future AFRS research and care, including patient management, diagnostic criteria, severity, pathophysiology, and related conditions. A summary of these clinical and associated research discussions is included below.

Background: Advancements in endoscopic sinus and skull base surgery created a need for standardized terminology to describe sphenoid sinus surgery. Although classification systems exist for other sinuses, one for endoscopic sphenoid sinus surgery is lacking. Developing such a system would standardize procedure descriptions and promote a common language among surgeons. This study aimed to develop a new classification system for endoscopic sphenoid surgery. Methods: Consensus on a novel endoscopic sphenoid surgery classification system by running the Delphi procedure with 16 rhinology experts from around the world. Results: Four Delphi rounds were required to reach a consensus on all stages of the classification. The average percentage of agreement on the stages of classification progressively increased from 70.83% in the first round to 87.68% in the last round. The rejection rates continuously decreased from 8.81% in the first round to 4.44% in the last round. The classification system was developed as follows: stage 1, presphenoid surgery; stage 2A, partial sphenoidotomy; stage 2B, complete sphenoidotomy; stage 2C, transpterygoid sphenoidotomy; stage 3A, Rostral sphenoidectomy; and stage 3B, extended sphenoid drill‐out. Conclusions: This novel endoscopic sphenoid surgery classification system facilitates the description of different sphenoid sinus procedures, providing surgeons with better opportunities for discussion and communication.

Background: Type 2 biologics have been used increasingly for the treatment of chronic rhinosinusitis with nasal polyps (CRSwNP). However, patterns of biologic switching are understudied, and established guidelines for sequential or simultaneous use do not yet exist.Methods: This is a Canadian multicenter retrospective study of real‐world patient data. Patients were included if they had recurrent CRSwNP despite maximal medical and surgical management, and received at least one dose of a type 2 biologic. Patients who remained on their initial biologic comprised the continuous group. Patients with sequential or simultaneous use of more than one biologic comprised the switched group. We compared the characteristics of patients who continued and switched biologics.Results: Note that 225 consecutive patients were included. Thirty‐six (16%) switched biologics at least once, and six (3%) switched twice. The most common switch was from mepolizumab to dupilumab, with poor control of CRSwNP symptoms being the leading cause for this switch. Lack of efficacy was the main reason for switching off mepolizumab and omalizumab, while adverse events were the leading cause for switching off dupilumab. Additionally, mepolizumab patients were more likely to switch biologics late in their treatment, while dupilumab patients rarely switched after 12 months of therapy (p‐value < 0.001).Conclusions: Switching biologics for CRSwNP is frequent in Canadian rhinology practices, with 16% of patients switching at least once. The most common switch is from mepolizumab to dupilumab with inadequate CRSwNP control driving this switch. This study may help guide sequential or simultaneous use of biologics in CRSwNP patients.

Patients with chronic rhinosinusitis (CRS) that is refractory to maximal medical and surgical therapy should be evaluated for other primary conditions. Cystic fibrosis (CF), primary immunodeficiency (PID), and primary ciliary dyskinesia (PCD) are potential risk factors for refractory CRS. These conditions present with variable disease severity and diagnosis may be delayed into adulthood. We report a case of a mother-daughter pair with CRS refractory to maximal medical management. The patients were further evaluated and found to have features consistent with CF, PID, and PCD. All 3 are rare disorders and thought to cause CRS in isolation. Patients with refractory CRS should be further evaluated to identify alternative diagnoses and ensure proper management. Refractory CRS may be multifactorial, with different risk factors simultaneously contributing to its persistence.