Dear Editors,

We would generally agree with comments made by Walker et al., which, firstly, relate to placing the onus upon the operating surgeon, and, secondly, consider an alternative conclusion that may be derived from the ENT-UK panel study that suggested improvement in peri-operative safety would be achieved in part by enhancing the otolaryngologist's ability to evaluate and interpret paranasal sinus computed tomography imaging.Reference Mistry, Strachan and Loney ¹ When compared to the radiologist, one specific area where the surgeon will gain advantage pertains to the feedback gained from the intra-operative findings, thus enabling them to correlate clinical and radiological features in an interchangeable manner.

As alluded to in the main article, there are several reasons why this topic remains controversial.Reference Mistry, Strachan and Loney ¹ In the UK, functional endoscopic sinus surgery (FESS) is commonly performed by the non-rhinologist. Analysis of individual responses to the panel survey highlighted the variation in expertise for performing FESS, which correlated to an apparent lack of confidence in the dissection of certain anatomical sites. The relationship between this expertise and reliance upon ‘formal’ radiological reporting was present during subgroup analysis.

Our study aimed not to contest the importance of these areas per se, but, more specifically, to gain an opinion from the UK otolaryngologist who practises FESS as to which structures would be relevant to them when included in a formal radiological report, which in turn can help radiologists compile surgically relevant reports for those who use them routinely. We have postulated within our discussion why several ‘key’ areas did not attain ‘vital importance’ status, which may in part be related to the level of expertise in performing FESS. Anatomical studies and checklists of important areas relating to FESS have been previously described in the literature.Reference Lloyd, Lund and Scadding ^{2 –} Reference Zinreich, Kennedy, Rosenbaum, Gayler, Kumar and Stammberger ⁴ These have all identified the key or ‘vital’ sites that pose the greatest risk of morbidity and mortality (e.g. lamina papyracea, skull base, dehiscence of carotid). There is no doubt that these well-described areas, which have been re-iterated by Walker et al. in their letter, must be thoroughly assessed prior to any sinus dissection in their proximity.