Maxillary Antrostomy Research Articles

Evaluation of resident's training for endoscopic sinus surgery using a sheep's head.

Training in functional endoscopic sinus surgery (FESS) is an essential part of each ENT resident and it takes place on a very fragile area. This study focus on showing the learning curve of FESS, using an anatomical model such as the sheep's head. Four residents in our centre performed dissections. Each of these residents operated eight sheep's head. They performed an endoscopic septoplasty followed by maxillary antrostomy, total ethmoidectomy and frontal sinusotomy on every head. A staff member guided all procedures and checked for the appropriate dissection and complications occurred. Analysis was made upon the residents' performance of their first four septoplasties and eight nasal sides against their subsequent performance of the same. Final procedures presented better outcomes than the initial ones on every step of them. Results were measured by means of decrease of time (P<0.0001) and complications, showing no major complications on the latest ones. Sheep's head is a suitable substitute for the cadaveric human head, to obtain the surgical skills needed for FESS procedures. Sheep's nasal cavity allows gaining dexterity and it is an easy model to obtain.

Characterizing Airflow Profile in the Postoperative Maxillary Sinus by Using Computational Fluid Dynamics Modeling: A Pilot Study

Maxillary antrostomy is commonly performed during endoscopic sinus surgery. Little is known about the association surrounding recalcitrant maxillary sinusitis, antrostomy size, and intranasal airflow changes. Furthermore, the interaction between sinus mucosa and airflow is poorly understood. This study used computational fluid dynamics (CFD) modeling to investigate postoperative airflow characteristics between diseased and nondiseased maxillary sinuses in subjects with recurrent disease. A retrospective review of patients from a tertiary-level academic rhinology practice was performed. Seven subjects with endoscopic evidence of postoperative maxillary sinus disease that presented as chronic unilateral crusting at least 1 year after bilateral maxillary antrostomies were selected. A three-dimensional model of each subject's sinonasal cavity was created from postoperative computed tomographies and used for CFD analysis. Although the variables investigated between diseased and nondiseased sides were not statistically significant, the diseased side in six subjects had a smaller antrostomy, and five of these subjects had both reduced nasal unilateral airflow and increased unilateral nasal resistance on the diseased side. The ratio of posterior wall shear stress (WSS) of the maxillary sinus to the total WSS was higher on the diseased side in six subjects. Results also showed strong correlations between antrostomy and CFD variables on the diseased side than on the nondiseased side. This pilot study showed that the majority of the simulated sinonasal models exhibited common characteristics on the side with persistent disease, such as smaller antrostomy, reduced nasal airflow, increased nasal resistance, and increased posterior WSS. Although statistical significance was not established, this study provided preliminary insight into variables to consider in a larger cohort study.

Anatomic findings in revision endoscopic sinus surgery: Case series and review of contributory factors.

Background:It is recognized that patients who undergo endoscopic sinus surgery (ESS) do not always achieve control of their disease. The causes are multifactorial; variations in surgical practice have been identified as possible factors in refractory disease.Objective:To reflect on the frequent anatomic findings of patients with chronic rhinosinusitis (CRS) who require revision ESS.Methods:A retrospective review of patients who required revision ESS at a tertiary institution over a 3-year period. Patients for whom maximal medical therapy failed for CRS underwent computed tomography of the paranasal sinuses and image-guided surgery. Surgical records of anatomic findings were reviewed and analyzed.Results:Over 3 years, a total of 75 patients underwent revision procedures, 28% of all ESS performed in the unit. The most frequent finding was a residual uncinate process in 64% of the patients (n = 48); other findings included a maxillary antrostomy not based on the natural ostium of the maxillary sinus in 47% (n = 35), an oversized antrostomy in 29% (n = 22), resected middle turbinates in 35% (n = 26), middle meatal stenosis in 15% (n = 11), synechiae in 29% (n = 22), and osteitic bone that required drilling in 13% (n = 10).Conclusion:Surgical technique can give rise to anatomic variations that may prevent adequate mucociliary clearance and medication delivery, which leads to failure in ESS in patients with CRS. This study demonstrated the surgical findings encountered in revision ESS that should be highlighted in the training of Ear, Nose and Throat surgeons to help prevent primary failure and reduce health care costs.

REMODEL larger cohort with long-term outcomes and meta-analysis of standalone balloon dilation studies.

Objectives/HypothesisTo provide the final results from the REMODEL (randomized evaluation of maxillary antrostomy versus ostial dilation efficacy through long‐term follow‐up) full‐study cohorts and perform meta‐analyses of standalone balloon sinus dilation studies to explore long‐term outcomes in a large patient sample.Study DesignRandomized controlled trial and meta‐analysis.MethodsFinal outcomes from the REMODEL randomized trial, including a larger cohort of 135 patients treated with functional endoscopic sinus surgery (FESS) or in‐office balloon dilation, were evaluated. One hundred thirty patients had 12‐month data, 66 had 18‐month data, and 25 had 24‐month data. In addition, a meta‐analysis evaluated outcomes from six studies including 358 standalone balloon dilation patients with up to 24 months follow‐up.ResultsOutcomes out to 2 years from the REMODEL full‐study cohort are consistent with 6‐month and 12‐month outcomes. In the meta‐analysis of standalone balloon dilation studies, technical success is 97.5%, and mean 20‐item Sino‐Nasal Outcomes Test scores are significantly and clinically improved at all time points (P < .0001). There are significant reductions (P < .0001) in work/school days missed, homebound days, physician/nurse visits, acute infections, and antibiotic prescriptions. Mean recovery time is 1.4 days. Comparison of 12‐month symptom improvements and revision rates between the REMODEL FESS arm (n = 59), REMODEL balloon dilation arm (n = 71), and pooled single‐arm standalone balloon dilation studies (n = 243) demonstrated no statistical difference.ConclusionsAll outcomes are comparable between FESS and balloon dilation at all time points from 6 months to 24 months. Balloon dilation produces faster recovery, less postoperative pain, and fewer debridements than FESS. There is significant, durable benefit in a large series of 358 patients undergoing standalone balloon dilation.Level of Evidence1b. Laryngoscope, 126:44–50, 2016

“Cahul” ozonated mineral water in the treatment of experimentally induced chronic rhinosinusitis

Abstract BACKGROUND. Chronic maxillary sinusitis is a frequently encountered pathology, resistant to treatment, which can cause significant economic losses. Considering these aspects, it is necessary to develop new methods of treatment. OBJECTIVE. The purpose of this study was to assess the therapeutic efficacy of the “Cahul” ozonated mineral water in the treatment of experimentally induced chronic rhinosinusitis and its action on the mucosa of the maxillary sinus. MATERIAL AND METHODS. The experimental study was conducted on a group of 14 chinchilla rabbits, aged between 8 and 12 months, weighing 2.5-3.0 kg, kept in vivarium conditions. In the first stage of the study, chronic rhinosinusitis was induced. 3 months after, maxillary antrostomy in the medial wall was performed on all animals included in the study; the intervention was performed under general anesthesia. The rabbits were divided into two groups. The rabbits enrolled in the study group underwent daily inhalations and maxillary sinus lavage with the “Cahul” ozonated mineral water. In the control group, inhalations and lavage were performed with 0.9% NaCl solution. Efficacy of the treatment was assessed observing the clinical character of the pathology. On days 2, 5 and 9 of the experiment, endoscopic and histological examinations were performed. RESULTS. On the ninth day of treatment, if in the study group the appearance of the sinus mucosa was almost normal, in the control group, the histological examination revealed: epithelial hyperplasia, cylindrical cell hyperplasia, thickening of the basement membrane and lymphocyte infiltration. Mucosal fragments harvested after 5 days revealed submucosal fibrosis, leukocyte infiltration in the control group being more pronounced than in the study group. CONCLUSION. Maxillary sinus lavage with the “Cahul” ozonated mineral water improves mucociliary clearance and stimulates regeneration of affected cells.

Outcomes of complete vs targeted approaches to endoscopic sinus surgery

Functional endoscopic sinus surgery (FESS) was historically predicated on targeted widening of narrow anatomic structures that caused postobstructive persistent sinus inflammation. It is now clear that chronic rhinosinusitis (CRS) is a multifactorial disease with subsets of patients which may require a more extensive surgical approach. This study compares quality-of-life (QOL) and disease severity outcomes after FESS based on the extent of surgical intervention. Participants with CRS were prospectively enrolled into an ongoing, multi-institutional, observational, cohort study. Surgical extent was determined by physician discretion. Participants undergoing bilateral frontal sinusotomy, ethmoidectomy, maxillary antrostomy, and sphenoidotomy were considered to have undergone "complete" surgery, whereas all other participants were categorized as receiving "targeted" surgery. Improvement was evaluated between surgical subgroups with at least 6-month follow-up using the 22-item Sino-Nasal Outcome Test (SNOT-22) and the Brief Smell Inventory Test (B-SIT). A total of 311 participants met inclusion criteria with 147 subjects undergoing complete surgery and 164 targeted surgery. A higher prevalence of asthma, acetylsalicylic acid (ASA) sensitivity, nasal polyposis, and a history of prior sinus surgery (p ≤ 0.002) was present in participants undergoing complete surgery. Mean improvement in SNOT-22 (28.1 ± 21.9 vs 21.9 ± 20.6; p = 0.011) and B-SIT (0.8 ± 3.1 vs 0.2 ± 2.4; p = 0.005) was greater in subjects undergoing complete surgery. Regression models demonstrated a 5.9 ± 2.5 greater relative mean improvement on SNOT-22 total scores with complete surgery over targeted approaches (p = 0.016). Complete surgery was an independent predictor of greater postoperative SNOT-22 score improvement, yet did not achieve clinical significance. Further study is needed to determine the optimal surgical extent.

What is the optimal maxillary antrostomy size during sinus surgery?

To review all the journal articles relevant to chronic maxillary sinusitis in order to discuss the optimal size of maxillary antrostomy during endoscopic sinus surgery. Although endoscopic maxillary antrostomy is a longstanding and frequently performed procedure, there is limited evidence about the optimal size of the antrostomy. Commonly employed surgical options include dilation via balloon sinuplasty, traditional antrostomy with uncinectomy using forceps and powered microdebriders, enlargement of the natural ostium, and the mega-antrostomy or modified medial maxillectomy. Historically, inferior antrostomies or nasal-antral windows were commonly utilized in the preendoscopic era, although this procedure is less commonly used today. Balloon sinuplasty can be effective in dilating the ethmoid infundibulum and natural ostium for select patients with isolated maxillary sinusitis or mild disease. A standard antrostomy using biting forceps and powered instrumentation is more appropriate for advanced disease such as severe mucosal hyperplasia or nasal polyps, as it allows for visualization of the maxillary sinus cavity and more effective topical delivery of saline irrigations and medications. For recalcitrant maxillary sinusitis, the mega-antrostomy allows for gravity-dependent drainage and is most appropriate for patients with inherent mucociliary defects.

English

Malignant nerve sheath tumours (syn: Neurogenic sarcoma, Neuro fibro sarcoma) comprise approximately 5% of all soft tissue sarcomas. Only 8to15% of these tumours arises in Head and neck region. Commonest sites in head and neck region are lateral skull base or along the course of cranial nerves. These tumours in sino nasal region are extreme rare. In this article we report a rare case of low grade MPNST. The tumour was resected by medial maxillectomy via modified Denker extended maxillary anterior antrostomy, resected tumour Histopathological examination and immunohistochemistry study reported as low grade MPNST and negative for s-100 protein. Patient was relieved from symptoms and followed for 18 months.

Bioabsorbable steroid-releasing sinus implants in the frontal and maxillary sinuses: 2-year follow-up.

Background:Mometasone furoate-releasing implants have been approved for use in the ethmoid sinuses following endoscopic sinus surgery (ESS) to reduce the need for medical and surgical intervention postoperatively. Outcomes have not yet been studied when these implants are utilized in other paranasal sinuses after ESS.Objective:To present a case in which bioabsorbable steroid-eluting implants were used to maintain patency and to decrease inflammation in the frontal and maxillary sinuses after revision ESS.Methods:52-year-old male with lifelong allergic rhinitis, chronic allergic fungal rhinosinusitis, and inflammatory bowel disease had previously undergone four endoscopic sinus surgeries, subcutaneous injection immunotherapy, and topical therapy with budesonide and amphotericin sinus irrigations. In July, 2012, during revision left frontal sinusotomy and right maxillary antrostomy (the fifth ESS), two bioabsorbable steroid-releasing implants were placed in the left frontal recess and the right maxillary sinus respectively and followed clinically, endoscopically, and radiographically for two years.Results:Two year followup demonstrated near complete clinical, endoscopic, and radiographic resolution of the patient's signs and symptoms of chronic rhinosinusitis.Conclusions:The steroid-releasing implants during the critical phase of wound-healing appear to have allowed the patient, now over two years postoperatively, to achieve a healthier state and to allow more successful management than the preceding 15–20 years.

Objective radiographic density measurements of sinus opacities are not strong predictors of noninvasive fungal disease.

High-density paranasal sinus opacities are often deemed consistent with fungal elements. No studies of objective quantitative radiographic density measures have been performed to support this assertion. A consecutive series of 120 patients with chronic rhinosinusitis who underwent maxillary antrostomy with microbiological evaluation of contents within 60 days of sinus computed tomography scanning was investigated. Radiographic density characteristics of opacities in cultured maxillary sinuses (minimum, maximum, average, and standard deviation of Hounsfield units [HUstd]) were recorded. Receiver operator characteristic (ROC) curves were used to analyze the accuracy of radiographic characteristics in predicting fungal opacities. Of 133 maxillary sinus opacities, 22 were ultimately consistent with noninvasive fungal disease: 11 allergic fungal rhinosinusitis and 11 fungal balls. Fungal balls had higher-density components and were more heterogeneous and allergic fungal mucin was generally more radiodense. These findings were reflected by statistically significant ROC curves for maximum HU (p = 0.019) and HUstd (p = 0.023) for fungal balls and for average HU (p = 0.002) for allergic fungal mucin. A maximum HU cutoff of 334.0 detected fungal balls with 90.9% sensitivity and 72.7% specificity. An average HU cutoff of 42.9 HU detected allergic fungal mucin with 100% sensitivity and 46.3% specificity, although specificity improved to 73.2% with inclusion of nasal polyposis as a second requirement. Higher average HU more accurately predicts allergic fungal mucin whereas heterogeneity/high-density components more accurately predict fungal balls. No objective radiographic density measure, in isolation, is both sensitive and specific in predicting noninvasive fungal sinusitis.

Cholesteatoma of the maxillary sinus: a case report and review of the literature

Cholesteatoma is a relatively common disease entity within the middle ear cavity, but it is rarely found in the paranasal sinuses. We describe a rare case of cholesteatoma in the maxillary sinus of an elderly man presenting with recurrent sinus infections and nasal obstruction refractory to medical treatment. The patient was treated using functional endoscopic sinus surgery with successful removal of the cholesteatoma. He has no recurrence of the cholesteotoma at a 13year follow-up. We review the literature and history on maxillary cholesteatomas and discuss the theories on the pathogenesis of cholesteatoma formation. We propose functional endoscopic sinus surgery with maxillary antrostomy and marsupialization of the cholesteatoma as a primary treatment option for a maxillary cholesteatoma.

Combined maxillary sinus floor elevation and endonasal endoscopic sinus surgery for coexisting inflammatory sinonasal pathologies: a one-stage double-team procedure.

To report our experience with combined one-stage double-team maxillary sinus floor elevation (SFE) and endonasal endoscopic sinus surgery (ESS) procedure for concomitant inflammatory sinonasal pathologies. Clinical records of all patients that underwent maxillary SFE in conjunction with endonasal ESS for the treatment of inflammatory sinonasal pathologies between 2011 and 2013 were retrospectively reviewed. All included patients had a sinonasal-related pathology that was first suggested by the referring physician and was later confirmed clinically and radiographically by our combined team comprised of otorhinolaryngologist and maxillofacial surgeons. Fifteen combined SFE+ESS surgeries were performed using either xenograft-allograft mixture or autograft-xenograft-allograft mixture. The study group included seven males and eight females, whose median age was 55years (range, 45-78years). Seven patients underwent a unilateral SFE, and eight patients underwent bilateral SFEs. During the same session, four patients also underwent septoplasty for deviated nasal septum, five patients underwent bilateral maxillary antrostomy, 10 patients underwent unilateral maxillary antrostomy, and six patients underwent maxillary sinus cyst resection. Seven combined procedures were performed under active infection. There were no intra-operative complications, and all SFE+ESS combined procedures were successful. Three patients required extended postoperative antibiotic treatment for persistent sinusitis. One patient reported infraorbital hypoesthesia. We first report the promising outcomes of the double-team one-stage SFE+ESS procedure performed by a combined team of otorhinolaryngologist and maxillofacial surgeons, including on patients presenting with an infection of the sinuses at the time of surgery.

Extended inferior meatal maxillary antrostomy through inferior turbinate reversing approach for maxillary lesions

To explore the feasibility of the extended inferior meatal maxillary antrostomy through inferior turbinate reversing approach. Eight patients underwent extended inferior meatal maxillary antrostomy through inferior turbinate reversing approach for maxillary sinus lesions. The indications, surgical management and outcomes of the surgery were presented. There were 2 cases of maxillary dentigerous cyst with oroantral fistula, 2 cases of antrochoanal polyp, 2 cases of maxillary sinus inverted papillomas, 1 case of odontogenic maxillary sinusitis with oroantral fistula, and 1 case of maxillary sinus mucocele. All patients underwent extended inferior meatal maxillary antrostomy through inferior turbinate reversing approach without intraoperative complication, with good access to the lesions. Complete resection could be achieved through this approach, no postoperative complications occurred except one patient had a delayed wound healing of inferior turbinate, all patients were free of recurrence with the average postoperative follow-up of 7.8 months (range 4-12 months). The extended inferior meatal maxillary antrostomy through inferior turbinate reversing approach is recommended for some maxillary pathology owing to its good access to the lesions and complete resection.

Maxillary sinus posterior wall remodeling following surgery for silent sinus syndrome

Silent SINUS SYNDROME is a clinical syndrome defined by unilateral maxillary sinus opacification with atelectasis of the uncinate process. Clinically, this disorder is characterized by enophthalmos and hypoglobus. The current case report illustrates dramatic bony remodeling of the maxillary sinus following maxillary antrostomy. Although the remodeling is noted in the posterior wall of the maxillary sinus, this demonstrates the dynamic nature of bone remodeling in silent sinus syndrome, which may obviate the need for surgical correction of enophthalmos and hypoglobus. Following maxillary antrostomy, observation with staged orbital surgery, if required, is recommended.

An Infant With Right Eye Proptosis

Apreviouslyhealthy, full-termwhitemale infantpresentedwithconcernfordiplopiaanda2-monthhistoryof jerkingrighteyemovements. Physicalexaminationrevealedmildrighteyeproptosis.Findings from anterior rhinoscopywereunremarkable.Magnetic resonance imaging (MRI) showeda4.2 × 2.7 × 2.8-cmexpansileosseousmasscentered in the sphenoid sinus and right posterior ethmoid sinus, resulting in clinicallysignificantnarrowingof therightand leftopticcanalsandorbital apices, rightmedial rectusdeviation, and sellar compression.A representative,noncontrast,coronalT1-weightedMRIshowedthe lesion in the posterior ethmoid sinuses with displacement of themedial rectusandremodelingof themedialorbit (Figure,A).Acontrastenhancedcomputedtomographic (CT) scanshowedthe lesion tobe well definedand lobulated. Thematrix of the lesionwas isodense to hyperdense as a result of psammomatoid ossicles, and small calcificationswere later demonstrated through histological studies. The patient was initially taken to the operating room for endoscopic nasal examination with biopsy. Grossly, the lesion was remarkable for an eggshell-like outer surface giving way to a granular consistency internally (Figure, B). Histologically, the tumor was notable for focal ly psammomatous and ramifying calcifications with eosinophilic rims embedded within a cellular mesenchymal framework composed of spindledshaped cells and variable amounts of vascular spaces (Figure, C and D). Twomonths later, thepatientunderwent a total right ethmoidectomy, maxillary sinus antrostomy, and right anterior orbitotomy withdebulkingof tumor, resulting in symptomatic improvement.At present, thepatient isbeingclosely followed forprogressionof skull base disease. What is your diagnosis? A B

Regional Variation and Factors Associated With Image Guidance Utilization During Endoscopic Sinus Surgery in the Ambulatory Setting

Determine regional variation and factors associated with the use of image guidance (IG) during endoscopic sinus surgery (ESS) in the ambulatory surgery center setting. All cases of ESS in 2010 were extracted from the state ambulatory surgery databases for New York, North Carolina, Florida, Iowa, and California. Current Procedural Terminology codes for individual sinusotomies and IG and International Classification of Diseases codes along with insurance and regional data were analyzed to determine factors that were associated with the use of IG during ESS. Among 36 646 ambulatory ESS procedures (mean age 46.0 years; 49.0% female), 6676 cases utilized IG (18.2%). Polyps were present in 27.9% of cases. North Carolina had the highest utilization rate for IG (26.0%), whereas Iowa had the lowest (12.8%). On multivariate analysis, use of IG was associated with state, insurance status, community setting, total ethmoidectomy, frontal sinusotomy, sphenoidotomy, and polyps (all P < .001), but not maxillary antrostomy (P = .197). The highest procedural odds ratio for IG use was noted for total ethmoidectomy (2.07), followed by frontal sinusotomy (1.97) and sphenoidotomy (1.26). Although IG is utilized in a relative minority of ESS cases, there is considerable regional variation in use. Factors other than complexity of surgery influence IG utilization as well.

Extended medial maxillary antrostomy

A subset of patients with chronic rhinosinusitis have difficult-to-treat or recalcitrant maxillary sinus disease. For these patients, standard maxillary sinusotomy techniques may not be adequate to allow the drainage of sinus contents or allow the application of topical medication to reduce severity of disease. Herein, we describe an extended maxillary antrostomy technique that creates a wide opening in the maxillary sinus and carries the opening inferiorly to the level of the nasal floor allowing for drainage of the maxillary sinus without necessitating mucociliary clearance to counteract gravitational forces necessary with typical maxillary opening techniques. This technique allows for in-office debridement of the maxillary sinus and gravity-independent application of topical medications and rinses.

Tracheal Re-Stenosis after Resection and Anastomosis of Complete Tracheal Stenosis

Tracheal Re-Stenosis after Resection and Anastomosis of Complete Tracheal Stenosis

Modifications to the Endoscopic Approach for Anterior Skull Base Lesions Improve Postoperative Sinonasal Symptoms

Background/Objective Our institution previously showed that patients experience significant postoperative sinonasal symptoms for the first few months after endoscopic transnasal transsphenoidal skull base surgery (eTNTS). Since our initial study we have modified our technique, discontinuing routine resection of the middle turbinate, maxillary antrostomies, and nasoseptal flaps. In this study, we analyze whether these technical modifications decrease postoperative sinonasal morbidity after eTNTS. Methods A retrospective review was performed of 93 consecutive patients who underwent eTNTS at a tertiary academic medical center from August 2011 to August 2012. Main Outcome Measures Sino-Nasal Outcome Test (SNOT)-20 and SNOT-22 scores preoperatively and after surgery. Results Compared with our previous study, our new cohort experienced a significant improvement (p < 0.05) in SNOT scores for the need to blow nose, runny nose, postnasal discharge, thick nasal discharge, wake up at night, reduced concentration, and frustrated/restless/irritable. Within the new cohort, patients who did not have a nasoseptal flap or middle turbinate resection had less worsening and faster improvement of nasal symptom scores after surgery. Conclusions Preserving normal sinonasal physiology during eTNTS by limiting middle turbinate resections, avoiding unnecessary maxillary antrostomies, and reducing the use of nasoseptal flaps when feasible results in less sinonasal morbidity and more rapid recovery during the postoperative period.

Achievement of competency in endoscopic sinus surgery of otolaryngology residents

The goal of our study is to identify the number of Endoscopic Sinus Surgery (ESS) cases required to obtain competency in ESS, using a previously validated assessment tool. Prospective observational study. Seventeen residents from Johns Hopkins Otolaryngology-Head & Neck Surgery residency program were evaluated as they performed endoscopic sinus surgery in the operating room. Global and checklist parts of the ESS instrument were used for assessment purposes. Items on the tool were grouped into three different milestones for analysis of data (Milestone 1 = Maxillary Antrostomy + Anterior Ethmoidectomy, Milestone 2 = Posterior Ethmoidectomy + Sphenoidostomy, Milestone 3 = Frontal Sinusotomy). Residents were deemed competent if they achieved a minimum score of 3 on a 5-point Likert scale on each step of the surgery. A total of 73 evaluations were completed for 17 residents (Postgraduate Level 2-5) by eight evaluators between 2009 and 2011. A 60% probability of achieving competency in performance of all milestones of ESS is obtained with performing 42 ESS procedures and the probability is increased to a 100% with performance of 55 endoscopic sinus surgery procedures. On average it took residents 23 cases to become competent in performance of maxillary antrostomy and anterior ethmoidectomy. Our results suggest that it requires 42 ESS procedures to attain a 60% probability of competency in ESS. These results have implications for otolaryngology residency programs when developing curriculum and benchmarks for the training residents.