Objective We sought to identify a relationship between skull base height and anterior ethmoid artery (AEA) anatomy. Study Design Retrospective radiologic chart review. Setting University of Arkansas for Medical Sciences. Subjects Patients seen in a tertiary rhinology clinic between September 2014 and October 2015. Methods Review of 101 maxillofacial computed tomography scans with institutional review board approval. Skull base height and AEA locations were measured on each side. Prevalence of the AEA outside of the skull base and distance of the AEA from skull base were calculated and compared with Keros classification using χ testing. Comparisons of skull base height between sexes and age and distance between skull base and the AEA among Keros 2 and Keros 3 patients were made using an unpaired, 2-tailed t test. Results The AEA was located below the skull base in 25.7% of cases and more often in Keros type 3 (55%) than in Keros type 2 (29.5%) or Keros type 1 (0%) ( P < .05). Male patients were significantly more likely to have a greater average skull base height (5.25 vs 4.28 mm) and to have AEAs below the skull base (38.4% vs 14.8%). In addition, the distance of the AEA from the skull base was significantly higher in Keros type 3 patients compared with Keros type 2 patients (4.55 vs 3.42 mm, P = .001). Conclusions Variations in the AEA pathway occur more in male patients and those with higher Keros classifications. The distance between the variant AEA and the skull base increases with higher Keros classification. Keros classification can yield insight to the location of the AEA.

Objective The purpose of this study is to identify perioperative independent prognostic factors that are available to the consulting team to aid in determining prognosis in patients with acute invasive fungal sinusitis. Study Design Retrospective chart review of patients with biopsy-proven acute invasive fungal sinusitis from 2015 to 2018. Setting Academic tertiary care center. Methods Twenty-one patients were included from our single-center retrospective review. Kaplan-Meier graphs were created, and the Breslow test used to compare the curves to obtain P values. A univariate Cox regression analysis was performed on the data that were significant at 3 months from diagnosis. Results Twenty-one patients were included, and 17 (76%) had an underlying hematologic malignancy. Overall survival was 71% and 52% at 1 and 3 months, respectively, and 94% of patients with hematologic malignancy had an absolute neutrophil count ≤1 at diagnosis. Absolute neutrophil count values and fungal species were not associated with a difference in prognosis. Factors associated with decreased survival included current smoking and the absence of a rhinologist on the treatment team at the initial or subsequent debridement (hazard ratio, 3.03). Laboratory values such as beta-D-glucan and galactomannan were assessed in addition to disease extension at diagnosis. Conclusion This study presents a retrospective review of a single institution’s experience with acute invasive fungal sinusitis. Subspecialty level of care likely improves overall survival in these patients, whereas current smoking may imply a worse prognosis.

Background. While pituitary tumors are well understood, little research has been done on metastasis from primary tumors into pituitary adenomas, also known as composite tumors. Because only 34 cases of composite tumors have been reported to date, we hope to better characterize these tumors by reviewing cases reported in the literature and reviewed our own documented case, which includes next-generation sequencing. Case Presentation. A 74-year-old man presented to the emergency department with left vision loss for 3 months. He had a history of colon cancer treated with colectomy and clear cell renal carcinoma treated with left nephrectomy. A preoperative MRI demonstrated growth of a peripherally enhancing, centrally necrotic mass with sellar expansion measuring 5.7×3.1×3.0 cm. Given these findings, an endoscopic endonasal transsphenoidal resection was performed. Histological assessment revealed a composite tumor: one neoplasm was a nonfunctioning pituitary adenoma, and another neoplasm was a clear cell carcinoma. Next-generation sequencing demonstrated that the tumors shared mutations in VHL and Notch2. The patient died 2 months later from systemic metastatic cancer. Conclusion. From our literature review, most metastatic lesions in these composite tumors originated from neoplasms of the lung and kidney. Approximately 63% patients presented with ophthalmoplegia as the initial symptom while 23% displayed hormonal abnormalities. Postoperative mortality had a median of 3.5 months. In our patient, the presence of VHL and Notch2 mutations in both tumors highlights the possibility of using next-generation sequencing to help identify therapeutic targets even in complex composite neoplasms.

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The proportion of the population over 65 years old continues to grow. Chronic rhinosinusitis is common in this population and causes a reduction in quality of life and an increase in health care utilization. Diagnosis of chronic rhinosinusitis with nasal polyps follows the same principles for elderly patients as in the general population, but the elderly population presents some diagnostic challenges worth considering. Presbynasalis, the anatomic and functional changes of the nose and paranasal sinuses associated with aging must be accounted for when caring for these patients. In addition, polypharmacy and other medical issues that can cause similar symptoms must be considered. Medical therapy is generally similar to the general population but with additional concerns given the propensity for geriatric patients to be on multiple medications and to suffer from multiple medical issues. Sinus surgery should be considered following the same indications as in the general population. While some authors have found higher complication rates in endoscopic sinus surgery, others have found higher rates of success. As always, the risks of surgery must be considered with the possible benefits on a patient-to-patient basis.

Objectives: Spontaneous cerebrospinal fluid (CSF) rhinorrhea is a diagnostic challenge due to its overlapping symptomatology with other sinonasal diseases. The objective of this study was to investigate whether items on the sinonasal outcome test (SNOT)−22 could suggest a diagnosis of spontaneous CSF rhinorrhea versus chronic rhinosinusitis without nasal polyps (CRSsNP). Methods: A multi-institutional retrospective chart review of patients with spontaneous CSF rhinorrhea and a control group of CRSsNP patients was performed. Individual SNOT-22 scores and domain scores were compared. Results: One hundred fifteen patients were included in both cohorts. Of the patients in the CSF rhinorrhea group, 48% were misdiagnosed as chronic rhinosinusitis (CRS) prior to the correct identification of a CSF leak. On bivariate analysis, the CSF rhinorrhea group scored significantly higher on the SNOT-22 for runny nose ( P < .001) and was more likely to designate this symptom as most important ( P < .001). The CRSsNP group scored significantly higher in nasal blockage ( P < .001), thick nasal discharge ( P < .001), facial pain/pressure ( P < .001), and in the ear/facial ( P < .001) and rhinologic ( P = .003) domains. Multivariable logistic regression revealed that runny nose ( P < .001) was most predictive of spontaneous CSF rhinorrhea while nasal blockage ( P < .001), thick nasal discharge ( P < .001), and facial pain/pressure ( P = .001) were predictive of CRSsNP after adjusting for relevant confounders. No significant difference was observed in total SNOT-22 scores between groups ( P = .676). Conclusions: Spontaneous CSF rhinorrhea is commonly misdiagnosed as other sinonasal pathologies. However, individual SNOT-22 items can help aid in suggesting a CSF leak. Spontaneous CSF rhinorrhea should be suspected in patients who have high SNOT-22 scores for runny nose and report this symptom as most important, but have lower scores related to the other cardinal symptoms of CRS.

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