Objective: Next-generation sequencing increases the sensitivity of fungal identification and may improve our understanding of the role that fungi play in sinus health and disease, which remains incompletely understood. We sequenced the internal transcribed spacer (ITS) amplicon to explore the role of the mycobiome in chronic rhinosinusitis (CRS).Methods: Swabs were collected intraoperatively from the middle meatus of 90 patients (63 with CRS; 27 controls). DNA was extracted, and ITS amplicon concentration was measured using fluorometry. Internal transcribed spacer amplicons were sequenced on the Illumina MiSeq (Illumina Inc San Diego CA). Sequencing data were analyzed using QIIME.Results: Using conventional detection techniques of culture and histology, fungi only were identified in nine of 63 (14.3%) CRS patients (fungus-identified group); the remaining 54 CRS patients and all controls did not have fungus identified using the traditional techniques. This fungus-identified group had a significantly higher average ITS concentration and a significantly lower Shannon's diversity index compared to the other two groups. The most abundant organism sequenced was Aspergillus (35.22% of all sequences). Multivariate analysis showed that positive fungal detection using traditional techniques and computed tomography (CT) double densities were the most important clinical predictors of a high fungal biomass, whereas Lund-Mackay score, polyps, eosinophilia, and eosinophilic mucus were not significant in comparison.Conclusion: Fungal biomass estimated through ITS amplicon concentration correlated with traditional fungal detection techniques and CT double densities. Our results suggest that fungal dysbiosis only occurs in the sinuses of a selected subset of patients, and therefore could not be a universal determinant of sinus disease pathogenesis in all CRS patients.

Endoscopic and endoscopic-assisted approaches to the parapharyngeal space have been reported; however, their potential for vascular exposure has not been previously assessed. This study aims to compare the potential exposure and control of the parapharyngeal internal carotid artery (ppICA) via various approaches. Ten cadaveric specimens were dissected bilaterally, exposing the ppICA via endonasal, transoral, and transcervical approaches. Length of the exposed vessel and potential control were assessed (feasibility and time required to place an encircling suture). Endoscopic transoral and transcervical-transmandibular approaches expose a significantly longer segment of the ppICA (6.89 and 7.09 cm) than the transoral and endonasal approaches. Vascular control was achieved via endoscopic-endonasal, endoscopic-transoral, and open techniques in 121.6, 64.8, and 5.2 seconds, respectively. Histopathology, goals of surgery, and familiarity of the surgeon with each technique may ultimately determine the choice of approach; however, this study suggests that exposure of the ppICA by endoscopic-assisted transoral approach is comparable to that of a transcervical-transmandibular approach. Vascular control was feasible under elective circumstances. However, the difficulty varied widely, potentially reflecting the challenges of controlling an injured ppICA. However, one must note that active bleeding obscures the surgical field in ways that may impair ppICA control. Furthermore, the results may not reflect clinical scenarios where tumor distorts the surgical field. Nonetheless, the study suggests that, in properly selected patients, the endoscopic-assisted transoral approach avoids problems associated with unsightly scars, mandibular osteotomy, and facial nerve manipulation, whereas, the transcervical-transmandibular approach offers the swiftest vascular control.

Applying Mitomycin C topically after endoscopic sinus surgery could reduce the risk of nasal synechiae and maxillary sinus ostium stenosis in short term by 66% and 74%, respectively. The treatment effects may be more beneficial in patients aged 40 years or younger or in patients without history of revision. However, our results were based on pooling trials with questionable methodological quality. Further trials with good research methodology and long-term follow-up should be conducted to confirm our results.

Objective: This study aims to compare the potential sinus distribution between high-volume nasal irrigation and nasal spray in chronic rhinosinusitis (CRS) patients who have not undergone sinus surgery.

Objective This study aimed to evaluate the efficacy of corticosteroid irrigation compared to saline to no nasal irrigation in COVID‐19 patients with olfactory loss. Design and Setting A randomised controlled study was conducted at the Otolaryngology‐Head & Neck Surgery Department, Ramathibodi Hospital, Faculty of Medicine, Mahidol University. Participants Two hundred thirty‐seven COVID‐19 participants with a new‐onset smell loss were recruited into the study. Two hundred twenty‐two participants met the inclusion criteria and were randomised into three groups: corticosteroid irrigation, saline irrigation and no treatment. Main Outcome Measures The primary outcome was the mean difference in the smell sensation score among the groups after treatment at 1, 2 and 6 weeks. The secondary outcomes measurements included (1) a self‐rating quality of life (QOL)‐related smell dysfunction score, (2) the change over time in smell sensation score and self‐rating QOL‐related smell dysfunction score and (3) the median time to complete recovery of smell loss. Results The mean differences in smell sensation scores among the three groups were not statistically significant at any follow‐up period. The mean score of self‐rating QOL‐related smell dysfunction in the corticosteroid group was significantly better than the other groups at 1 week. The change of outcome scores showed significant improvement over time, regardless of the treatments. The median time to complete smell recovery was similar: 3 weeks. Conclusion This study emphasised that corticosteroid nasal irrigation is not superior to saline or no nasal irrigation in restoring the sense of smell in COVID‐19‐associated olfactory loss.

Background: Delayed postoperative cerebrospinal fluid (CSF) leaks are uncommon and largely unstudied complications. In this study we aim to identify their etiology and understand the efficacy of various reconstruction strategies. Methods:A retrospective chart analysis of 1017 endonasal skull base surgeries performed by a single neurosurgeon was completed identifying delayed CSF leaks (occurring >1 week a er surgery).Results: Seventeen cases of early (1-2 weeks a er surgery) or delayed (>2 weeks a er surgery) postoperative CSF leak were identified. The most common reconstruction during the initial surgery consisted of an inlay or gasket seal collagen matrix (82.4% of patients) with an onlay pedicled flap (76.5% of patients). Presenting symptoms of delayed CSF leak included rhinorrhea (82.4%), headache (41.2%), and meningitis (23.5%). The most common causes included flap dehiscence (17.6%); provoking events such as emesis, sneezing, or fall (17.6%); flap necrosis (11.8%); flap displacement (11.8%); and inadequate apposition of the flap, that is, folded flap (11.8%). Reconstructive techniques of the delayed CSF leak included fortification of the initial reconstruction with free fat gra s (29.4% of patients), combined collagen matrix with a fat gra (23.5% of patients), repositioning of the previous flap (11.8% of patients), and repair with a new flap (11.8% of patients). CSF diversion (spinal/ventricular drain or shunt) was used in 17.6% of patients. Conclusion:This study identifies the most common etiologic factors leading to a delayed CSF leak and its initial symptoms. Furthermore, it serves as the foundation for a reconstructive algorithm based on reinforcement of the initial repair with free abdominal fat gra with or without collagen matrix. C 2020 ARS-AAOA, LLC. Key Words: cerebrospinal fluid leak; nasoseptal flap; skull base reconstruction; skull base surgery How to Cite this Article: London NR, Jr, Mohyeldin A, Montaser AS, et al. Contributing factors for delayed postoperative cerebrospinal fluid leaks and suggested treatment algorithm. Int Forum Allergy Rhinol. 2020;10:779-784. T he primary goal of cerebrospinal fluid (CSF) leak repair is to re-establish a watertight seal between the

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