ObjectiveTo prospectively document the incidence, characteristics, and management of intraoperative and postoperative complications in elective septoplasty performed by supervised residents at a university teaching hospital.MethodsThis prospective longitudinal study enrolled 173 consecutive American Society of Anesthesiologists (ASA) class I patients (age 18-60 years) undergoing elective septoplasty at Al-Mouwasat University Hospital, Damascus. Procedures were performed by residents (PGY 3-4) under continuous attending supervision using the closed Killian technique. Postoperative care included intranasal packing removed on day 2 and Silastic splints removed on day 7, with monthly clinical follow-up for 3 months.ResultsThe cohort was predominantly male (111/173, 64.2%) with a mean age of 26.01 ± 7.65 years. Mean operative duration was 69.84 ± 23.46 minutes and mean intraoperative blood loss 151.45 ± 97.72 mL. Mucosal lacerations occurred in 139 patients (80.3%), of whom 84.9% required no intervention and 15.1% underwent suturing. Intraoperative bleeding resolved within 10 minutes in all but two cases (1.2%), which required electrocoagulation. Laceration size strongly correlated with blood loss (r = 0.634, p < 0.01). Over three months, no patient developed septal perforation, adhesions, postoperative hemorrhage requiring intervention, abscess, or cerebrospinal fluid leak. Minor events included nasal vestibulitis in two patients (1.16%) and postoperative vomiting in nine (5.2%).ConclusionDespite an 80.3% mucosal laceration rate, no major postoperative complication occurred. Prompt intraoperative recognition and selective repair of mucosal tears, rather than their avoidance, appears sufficient to prevent long-term sequelae, even in a supervised resident training setting.

Extranodal natural killer/T-cell lymphoma (ENKTL), nasal type, is an aggressive Epstein-Barr virus (EBV)-associated lymphoma that predominantly involves the nasal cavity and upper aerodigestive tract. Primary oral manifestations are rare and may clinically mimic benign inflammatory or infectious conditions, resulting in delayed diagnosis. This report presents a rare case of ENKTL initially manifesting as a rapidly progressive necrotizing palatal ulcer. A 44-year-old man presented with a three-week history of a necrotic ulcer on the posterior hard palate. Imaging revealed extensive midfacial destruction, including palatal perforation, nasal septal erosion, turbinate destruction, ethmoidal involvement, and medial orbital wall extension. Histopathologic examination demonstrated atypical large lymphoid cells with extensive necrosis and infiltration into adipose and muscle tissue. Immunohistochemical staining demonstrated diffuse expression of LCA and CD3, focal expression of CD30, absence of CD20, ALK, and CD56 expression, and a high proliferative activity, as evidenced by a Ki-67 index of approximately 90%. Based on the histomorphologic and immunophenotypic features, extranodal NK/T-cell lymphoma was suspected. Chromogenic in situ hybridization (CISH) for Epstein-Barr virus-encoded RNA (EBER) demonstrated strong nuclear positivity in atypical lymphoid cells, confirming the diagnosis of ENKTL, nasal type. The patient achieved complete remission after chemotherapy; however, eight months later, the patient developed a systemic relapse that was diagnosed as peripheral T-cell lymphoma. This case highlights the diagnostic complexity of ENKTL presenting as a destructive palatal lesion. Comprehensive histopathologic evaluation, detailed immunophenotyping, and EBV confirmation by EBER are essential for accurate diagnosis and timely oncologic management. ENKTL should be considered in the differential diagnosis of rapidly progressive oral necrotic lesions unresponsive to conventional therapy.

A 46-year-old woman without traditional vascular risk factors presented with one week of persistent vertigo and a nonfocal neurologic examination. Brain MRI revealed an acute to early subacute infarct in the left paramedian pons. CT angiography of the head and neck demonstrated no large-vessel disease, and a thrombophilia panel was unremarkable. Further evaluation identified a patent foramen ovale (PFO) with an atrial septal aneurysm and septal bowing, with a large right-to-left shunt on transthoracic echocardiography and a moderate shunt on transesophageal echocardiography bubble study. She had a Risk of Paradoxical Embolism (RoPE) score of 7 and met PFO-Associated Stroke Causal Likelihood (PASCAL) "Probable" criteria. Isolated paramedian pontine infarction is classically attributed to branch atheromatous disease, but the absence of small-vessel disease markers, the posterior circulation lesion location, and high-risk PFO anatomy together favored a paradoxical embolic mechanism. She received dual antiplatelet therapy followed by aspirin monotherapy, with referral for percutaneous PFO closure. This case illustrates how RoPE and PASCAL can help estimate whether a detected PFO is likely pathogenic rather than incidental in a perforator-territory stroke, and underscores that persistent vertigo without focal deficits warrants timely stroke imaging.

Eosinophilic granulomatosis with polyangiitis (EGPA) frequently presents with asthma and sinusitis, making otorhinolaryngologic manifestations potential early indicators of systemic vasculitis. However, these manifestations are often misdiagnosed as common inflammatory diseases. We report two cases of EGPA diagnosed based on distinct rhinologic presentations. The first case involved a 52-year-old woman who developed mononeuritis multiplex and cutaneous vasculitis following surgery for nasal polyps, which ultimately led to a definitive diagnosis of EGPA. The second case involved a 39-year-old woman who presented with nasal septal perforation and was subsequently diagnosed with an acute exacerbation of EGPA accompanied by pulmonary infiltrates. These cases highlight that not only nasal polyps but also atypical findings, such as nasal septal perforation, may serve as critical diagnostic clues for EGPA. Otorhinolaryngologists play a pivotal role in identifying this potentially fatal systemic vasculitis through careful evaluation of localized sinonasal manifestations.

Septal perforation repair remains technically challenging, particularly in defects requiring stable graft support for closure. We describe an endoscopic double-layer fascia lata technique and report surgical outcomes in a consecutive case series. Adult patients who underwent endoscopic septal perforation repair between 2022 and 2024 were reviewed, and 26 patients with perforations >1 cm were included. Perforations were measured in anterior-posterior and cranio-caudal dimensions, and graft size was determined according to the longest diameter. A fascia lata graft harvested from the thigh was folded to create a double-layer construct and secured with an absorbable suture. The graft was placed beneath the elevated mucoperichondrial flap and stabilized with bilateral splints for approximately 3 weeks. Complete closure was achieved in 24 patients (92.3%), while 2 patients with perforations ≥4 cm had partial closure. No perioperative or postoperative complications were observed.

Transcatheter edge-to-edge repair (TEER) requires precise echocardiographic guidance because the operator cannot directly visualize the mitral valve. Intraprocedural transesophageal echocardiography (TEE) is indispensable for safe and accurate device positioning and manipulation, whereas transthoracic echocardiography (TTE) plays a central role in preprocedural evaluation and serial postprocedural follow-up as part of comprehensive echocardiographic assessment. Before the procedure, echocardiography is essential for assessing the underlying mechanism and severity of mitral regurgitation (MR), determining anatomical suitability for TEER, and estimating procedural difficulty. Measurements such as mitral valve area, transmitral pressure gradient, tethering height, coaptation length, prolapse width and gap, as well as lesion location, leaflet morphology, and calcification distribution are crucial for predicting feasibility and technical complexity. During TEER, TEE must rapidly provide optimal views to guide each procedural step-from transseptal puncture to leaflet grasping and device deployment. Although X-plane imaging and three-dimensional reconstruction are now standard in many centers, live multiplanar reconstruction allows optimal imaging planes to be reconstructed in real time from acoustically favorable probe positions chosen to minimize device-related shadowing, thereby facilitating accurate and efficient intraprocedural guidance. Intraprocedural TEE is also vital for the early detection of complications, including pericardial effusion, leaflet injury, and clinically significant iatrogenic atrial septal defect with right-to-left shunting, as well as for immediate post-deployment hemodynamic assessment. In the postprocedural period, TTE focuses on detection of residual MR, evaluation for iatrogenic mitral stenosis, identification of single-leaflet device attachment or leaflet perforation, and serial assessment of cardiac function. Recent risk scores for patient selection and prognostication underscore the importance of comprehensive, evidence-informed echocardiographic evaluation that integrates both morphological and hemodynamic information.

Intranasal corticosteroids (INCS) remain the cornerstone of pharmacologic treatment for allergic rhinitis (AR) because of their well-established anti-inflammatory efficacy and generally favorable benefit-risk profile. Nevertheless, concerns regarding local and systemic corticosteroid-related adverse events (AEs) continue to influence patient adherence, prescribing practices, and long-term treatment acceptance. In routine clinical practice, safety perception and corticosteroid-related concerns frequently influence adherence and formulation selection to a greater extent than differences in clinical efficacy, particularly in pediatric populations and in patients requiring prolonged continuous therapy. Differences in pharmacokinetic and pharmacodynamic properties, including systemic bioavailability, glucocorticoid receptor affinity, lipophilicity, protein binding, and extent of first-pass metabolism, are considered important safety profile determinants of currently available INCS formulations. Available evidence indicates that local AEs, particularly epistaxis, nasal irritation, dryness, and sensory discomfort, represent the most frequently reported treatment-related AEs across INCS formulations, although these events are generally mild, self-limiting, and infrequently treatment-limiting. Clinically significant structural nasal complications, including septal perforation or progressive mucosal injury, appear uncommon in currently available studies. Systemic AEs, including hypothalamic-pituitary-adrenal (HPA) axis suppression, ocular toxicity, growth impairment, or clinically meaningful effects on bone metabolism, have not been consistently demonstrated with currently used low-systemic-exposure formulations administered at recommended therapeutic doses. Although systemic glucocorticoid exposure has been associated with alterations in lipid metabolism, adipose tissue function, and metabolic homeostasis, currently available intranasal corticosteroids demonstrate minimal systemic exposure, making clinically relevant metabolic effects unlikely under recommended therapeutic conditions. Formulations such as mometasone furoate, fluticasone propionate, fluticasone furoate, and ciclesonide exhibit pharmacokinetic characteristics associated with minimal systemic exposure because of extensive first-pass metabolism and low oral bioavailability. Although substantial pharmacokinetic differences exist between currently available INCS formulations, direct comparative evidence demonstrating clinically meaningful superiority in systemic safety outcomes remains limited. Current evidence suggests that formulation-dependent differences are clinically more relevant with respect to local tolerability, sensory characteristics, patient preference, and long-term adherence than major systemic safety outcomes. Pediatric evidence is generally reassuring, although historical concerns regarding growth suppression associated with earlier corticosteroid formulations continue to influence clinical practice. Currently available evidence supports the use of modern INCS as effective and generally well-tolerated therapeutic options across adult and pediatric populations.

The retrograde approach to percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) is a technically demanding strategy that requires specialized expertise and knowledge. Septal collaterals are generally considered the safest route given their intramuscular course, which can help contain blood extravasation in the event of perforation. However, when septal navigation is not feasible and no other options remain, epicardial collaterals provide a valuable alternative route to achieve successful revascularization. Although CTO PCI via epicardial collaterals is more complex and carries a higher risk of serious complications, innovations such as low-profile microcatheters and specialized low tip load guidewires have significantly enhanced both safety and technical feasibility. Consequently, retrograde CTO PCI via epicardial collaterals represents an important alternative when no other options are available and, when performed by experienced operators, allows complete revascularization even in the most challenging anatomies. Given this background, the present review provides practical guidance for interventionalists, outlining the current state of the art in terms of devices and techniques for CTO PCI via epicardial collaterals, including recommendations for complication prevention and management.