European Position Paper on Rhinosinusitis and Nasal Polyps 2020

The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 is the update of similar evidence based position papers published in 2005 and 2007 and 2012. The core objective of the EPOS2020 guideline is to provide revised, up-to-date and clear evidence-based recommendations and integrated care pathways in ARS and CRS. EPOS2020 provides an update on the literature published and studies undertaken in the eight years since the EPOS2012 position paper was published and addresses areas not extensively covered in EPOS2012 such as paediatric CRS and sinus surgery. EPOS2020 also involves new stakeholders, including pharmacists and patients, and addresses new target users who have become more involved in the management and treatment of rhinosinusitis since the publication of the last EPOS document, including pharmacists, nurses, specialised care givers and indeed patients themselves, who employ increasing self-management of their condition using over the counter treatments. The document provides suggestions for future research in this area and offers updated guidance for definitions and outcome measurements in research in different settings. EPOS2020 contains chapters on definitions and classification where we have defined a large number of terms and indicated preferred terms. A new classification of CRS into primary and secondary CRS and further division into localized and diffuse disease, based on anatomic distribution is proposed. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, allergic rhinitis, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. All available evidence for the management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is systematically reviewed and integrated care pathways based on the evidence are proposed. Despite considerable increases in the amount of quality publications in recent years, a large number of practical clinical questions remain. It was agreed that the best way to address these was to conduct a Delphi exercise. The results have been integrated into the respective sections. Last but not least, advice for patients and pharmacists and a new list of research needs are included.Peer reviewe

Radiological and clinical interpretation of the patients with CSF leaks developed during or after endoscopic sinus surgery

Cerebrospinal fluid (CSF) leaks associated with endoscopic sinus surgery (ESS) are a rare complication related to anatomical and technical factors. The anatomical variations at skull base level are imperative to be detected preoperatively by CT scan to avoid this complication. Identifying the factors playing a role in the incidence of the CSF leaks during and after ESS and the common leak sites. A retrospective review of 24 patients presented with incidental CSF leaks, gathered from 1999 to 2016 was performed. Images interpretation of the skull base area was done using four parameters includes Keros classification, skull base slope, fovea plane and maxillary ethmoid height ratio (MER). Each parameter is classified into three types according to the anatomical configuration, then these parameters scores categorized according to the level of the safety into a level I, II and III, all levels were correlated with each other and with the site of leakage. It was found that the major group presented with the level I and the least group with level III safety, with an evidence of the most unsafe anatomical variation was the least relevant. Parameters measurements revealed that the larger group of the anatomical variation type III was in the MER and the commonest leak site was in the posterior ethmoidal roof. CT scan study of the skull base is crucial in delineating the variations and be a roadmap to proceed safely through the dissection remembering that incidental CSF leaks are multifactorial in etiology

How to preserve the olfaction in harvesting the nasoseptal flap in endoscopic skull base surgery

The introduction of nasoseptal flap for the skull base defects reconstruction in endoscopic endonasal approaches represents a revolution that dramatically reduced incidence of the cerebrospinal fluid leaks, however it may be associated with comorbidities like olfactory hypofunction. Objectives: We revise our anatomical knowledge and surgical experience in order to describe an easy and safe technique to avoid olfaction hypofunction. Methods (Surgical technique): A simple anatomical surgical landmark proposed for identification of the olfactory area on the septum, based on the anatomy of the lateral nasal wall. More specifically, the level of the common axilla of the turbinates can be utilized to identify the distribution of the olfactory fibers on the nasal septum. Results: There was no significant change in the subjective olfaction identification score in the postoperative period. Conclusion: The common axilla line considered as a crucial landmark and an easy way to spare olfaction during harvesting the nasoseptal flap