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1.  Rhinosinusitis and asthma: the missing link 
Purpose of review
Disease of the nose and sinuses is the most common co-morbidity associated with asthma. Rhinitis, sinusitis and asthma may represent part of one disease process with manifestations at different sites. The purpose of this review is to highlight significant new findings on the epidemiological and pathophysiological link between the upper and lower airway. Finally we will review recent data assessing the impact of treating sinonasal disease on both the development of asthma, and asthma control.
Recent findings
Studies illustrate that rhinitis is very common in asthma, and associated with worse asthma control. Rhinitis typically precedes the development of asthma. Even in patients with rhinitis without asthma there is evidence of subclinical change in the lower airways as measured by physiological changes and the presence of inflammatory mediators. There is much interest on the impact of treating allergic rhinitis on the development of asthma.
Rhinitis, sinusitis and asthma are likely part of one disease process. Treatment of established rhinitis may have some impact on measures of airway obstruction, but an effect on lower airway inflammation is yet to be established. Prospective studies are required to determine if treatment of rhinitis can prevent the development of asthma, and/or decrease airway inflammation to improve asthma outcomes in those with established asthma.
PMCID: PMC2774711  PMID: 19077701
rhinitis sinusitis asthma
2.  The role of fungi in diseases of the nose and sinuses 
Human exposure to fungal elements is inevitable, with normal respiration routinely depositing fungal hyphae within the nose and paranasal sinuses. Fungal species can cause sinonasal disease, with clinical outcomes ranging from mild symptoms to intracranial invasion and death. There has been much debate regarding the precise role fungal species play in sinonasal disease and optimal treatment strategies.
A literature review of fungal diseases of the nose and sinuses was conducted.
Presentation, diagnosis, and current management strategies of each recognized form of fungal rhinosinusitis was reviewed.
Each form of fungal rhinosinusitis has a characteristic presentation and clinical course, with the immune status of the host playing a critical pathophysiological role. Accurate diagnosis and targeted treatment strategies are necessary to achieve optimal outcomes.
PMCID: PMC3904040  PMID: 23168148
Acute; chronic; fungal; invasive; review; rhinosinusitis; sinusitis
3.  Sinonasal neuroendocrine carcinoma: impact of differentiation status on response and outcome 
Head & Neck Oncology  2011;3:32.
The impact of tumor differentiation on the behavior and response of sinonasal neuroendocrine carcinoma is unknown.
We performed a retrospective review of the patients treated for neuroendocrine carcinoma (NEC) of the nasal cavity or paranasal sinuses from 1992 to 2008 at MDACC.
The results of our study suggest that pathologic differentiation may not be a critical factor in the clinical management of patients with NEC of the sinonasal tract. This is in contrast to laryngeal and lung NEC for which pathological differentiation has traditionally guided clinical management.
Mutlimodality approach should be the cornerstone of treating sinonasal NEC regardless of their differentiation. Specifically, RT may provide durable local control for patients with moderately differentiated NEC if resection is not feasible or desirable, while surgical resection can benefit patients with chemo-resistant or radio-resistant disease.
PMCID: PMC3154852  PMID: 21794118
Neuroendocrine carcinoma; carcinoid tumor; poorly differentiated carcinoma; sinonasal tumor
4.  Endoscopic Resection of Solitary Fibrous Tumors of the Nose and Paranasal Sinuses 
Skull Base  2011;21(2):129-134.
Solitary fibrous tumors (SFTs) are uncommon neoplasms of mesenchymal origin that were first described as primary spindle-cell tumors of the pleura in 1931. Since then, infrequent case reports of extrapleural SFTs have been described including various subsites within the head and neck. Based on a review of the literature and a description of the endoscopic treatment of three patients with SFTs of the nasal cavity and ethmoid sinuses, the challenges associated with the management of sinonasal SFTs are discussed. Successful endoscopic resection was performed at a tertiary referral rhinology practice within a university center in three cases of sinonasal SFTs with no evidence of recurrence at 26, 35, and 49 months following resection. Summarized are the common presenting symptoms, appropriate diagnostic workup, and indicative computed tomography and magnetic resonance imaging appearance of SFTs. Further discussed are the challenge associated with accurate histological and immunohistochemical diagnosis, the difficulty in assessing the aggressiveness and malignant potential of these lesions, and the appropriate treatment and follow-up duration that these neoplasms require.
PMCID: PMC3312588  PMID: 22451814
Solitary fibrous tumor; endoscopic resection; sinus
5.  Incidental sinonasal findings identified during preoperative evaluation for endoscopic transsphenoidal approaches 
The endoscopic transsphenoidal approach (eTSA) to lesions of the sellar region is typically performed jointly by neurosurgeons and otolaryngologists. Occasionally, the approach is significantly altered by sinonasal disease, anatomic variants, or previous surgery. However, there are no current guidelines that describe which physical or radiological findings should prompt a change in the plan of care. The purpose of this study was to determine the incidence of sinonasal pathology or anatomic variants noted endoscopically or by imaging that altered preoperative or intraoperative management.
A retrospective review was performed of 355 consecutive patients who underwent combined neurosurgery–otolaryngology endoscopic sella approach from August 1, 2007 to April 1, 2011. Our practice in these patients involves preoperative otolaryngology clinical evaluation and MRI review. Intraoperative image guidance is not routinely used in uncomplicated eTSA.
The most common management alteration was the addition of image guidance based on anatomic variants on MRI, which occurred in 81 patients (35.0%). Eight patients (2.9%) were preoperatively treated with antibiotics and surgery was postponed secondary to acute or chronic purulent rhinosinusitis; two (0.7%) required functional endoscopic sinus surgery for medically refractory disease before eTSA. Five patients (1.8%) required anterior septoplasty intraoperatively for severe nasal septal deviation. Two patients (0.7%) had inverted papilloma and one patient had esthesioneuroblastoma identified preoperatively during rigid nasal endoscopy.
This is one of the larger reviews of patients undergoing eTSA for sellar lesions and the only study that describes how intraoperative management may be altered by preoperative sinonasal evaluation. We found a significant incidence of sinonasal pathology and anatomic variants that altered routine operative planning; therefore, a thorough sinonasal evaluation is warranted in these cases.
PMCID: PMC3649855  PMID: 23710956
Endoscopic; image-guided surgery; incidental; preoperative; sella; sinonasal; transsphenoidal
6.  Treatment trends in allergic rhinitis and asthma: a British ENT survey 
Allergic Rhinitis is a common Ear, Nose and Throat disorder. Asthma and Allergic Rhinitis are diseases with similar underlying mechanism and pathogenesis. The aim of this survey was to highlight current treatment trends for Allergic Rhinitis and Asthma.
A questionnaire was emailed to all registered consultant members of the British Association of Otorhinolaryngologists - Head and Neck Surgeons regarding the management of patients with Allergic Rhinitis and related disorders.
Survey response rate was 56%. The results indicate a various approach in the investigation and management of Allergic Rhinitis compatible with recommendations from the Allergic Rhinitis and Its Impact on Asthma guidelines in collaboration with the World Health Organisation.
A combined management approach for patients with Allergic Rhinitis and concomitant Asthma may reduce medical treatment costs for these conditions and improve symptom control and quality of life.
PMCID: PMC3090350  PMID: 21481237
Allergic Rhinitis; Asthma; Survey; Questionnaire; Atopy
7.  Sarcoidosis with involvement of the paranasal sinuses - a retrospective analysis of 12 biopsy-proven cases 
Extrapulmonary involvement by sarcoidosis is observed in about 30–40% of patients with sarcoidosis. Little is known about the frequency and clinical characteristics of sinonasal sarcoidosis.
We retrospectively analyzed 12 cases of biopsy-proven sinonasal sarcoidosis. Patients were identified from a patient population of 1360 patients with sarcoidosis at the Outpatient Clinic for Sarcoidosis and Rare Lung Diseases at LungClinic Grosshansdorf, a tertiary care hospital for respiratory medicine.
The most frequent signs and symptoms were nasal polyps (4 cases), epistaxis (3 cases), nasal crusts (8 cases) and anosmia (5 cases). Pulmonary sarcoidosis of the patients was staged as stage I (n = 1) and stage II (n = 11) on chest radiographs. Spirometry was normal in 11 patients. 7 patients had a diffusion capacity of the lung for carbon monoxide of less than 90% of predicted. Other organs were affected in 8 patients. All patients received systemic corticosteroid treatment and most patients received topical steroids. 5 patients received steroid sparing agents. Repeated sinus surgery had to be performed in 4 patients.
Sinonasal involvement is a rare disease manifestation of sarcoidosis with a frequency slightly lower than 1% in our patient population. The clinical course of sinonasal sarcoidosis can be complicated by relapse despite systemic immunosuppressive treatment and repeated sinus surgery.
PMCID: PMC3850727  PMID: 24070015
Sarcoidosis; Sinonasal involvement; Treatment of sarcoidosis
8.  Allergic rhinitis: evidence for impact on asthma 
BMC Pulmonary Medicine  2006;6(Suppl 1):S4.
This paper reviews the current evidence indicating that comorbid allergic rhinitis may have clinically relevant effects on asthma.
Allergic rhinitis is very common in patients with asthma, with a reported prevalence of up to 100% in those with allergic asthma. While the temporal relation of allergic rhinitis and asthma diagnoses can be variable, the diagnosis of allergic rhinitis often precedes that of asthma. Rhinitis is an independent risk factor for the subsequent development of asthma in both atopic and nonatopic individuals. Controlled studies have provided conflicting results regarding the benefits for asthma symptoms of treating comorbid allergic rhinitis with intranasal corticosteroids. Effects of other treatments for comorbid allergic rhinitis, including antihistamines, allergen immunotherapy, systemic anti-IgE therapy, and antileukotriene agents, have been examined in a limited number of studies; anti-IgE therapy and antileukotriene agents such as the leukotriene receptor antagonists have benefits for treating both allergic rhinitis and asthma. Results of observational studies indicate that treating comorbid allergic rhinitis results in a lowered risk of asthma-related hospitalizations and emergency visits. Results of several retrospective database studies in the United States and in Europe indicate that, for patients with asthma, the presence of comorbid allergic rhinitis is associated with higher total annual medical costs, greater prescribing frequency of asthma-related medications, as well as increased likelihood of asthma-related hospital admissions and emergency visits. There is therefore evidence suggesting that comorbid allergic rhinitis is a marker for more difficult to control asthma and worsened asthma outcomes.
These findings highlight the potential for improving asthma outcomes by following a combined therapeutic approach to comorbid allergic rhinitis and asthma rather than targeting each condition separately.
PMCID: PMC1698497  PMID: 17140422
9.  Sinonasal Tract Mucoepidermoid Carcinoma: A Clinicopathologic and Immunophenotypic Study of 19 Cases Combined with a Comprehensive Review of the Literature 
Head and Neck Pathology  2011;6(2):191-207.
Primary sinonasal tract mucoepidermoid carcinomas (MEC) are uncommon tumors that are frequently misclassified, resulting in inappropriate clinical management. The design of this study is retrospective. Nineteen cases of MEC included 10 females and 9 males, aged 15–75 years (mean, 52.7 years); males, on average were younger by a decade than females (47.2 vs. 57.7 years). Patients presented most frequently with a mass, obstructive symptoms, pain, and/or epistaxis present for a mean of 12.6 months. The majority of tumors involved the nasal cavity alone (n = 10), maxillary sinus alone (n = 6), or a combination of the nasal cavity and paranasal sinuses (n = 3) with a mean size of 2.4 cm. Most patients presented at a low clinical stage (n = 15, Stage I & II), with only 4 patients presenting with Stage III disease. Histologically, the tumors were often invasive (bone or perineural invasion), with invasion into minor mucoserous glands. Surface involvement was common. The neoplastic cells were composed of a combination of squamoid cells, intermediate cells, and mucocytes. Cystic spaces were occasionally large, but the majoritywere focal to small. Pleomorphism was generally low grade. Necrosis (n = 5) and atypical mitotic figures (n = 6) were seen infrequently. Over half of the tumors were classified as low grade (n = 11), with intermediate (n = 4) and high grade (n = 4) comprising the remainder. Mucicarmine was positive in all cases tested. Immunohistochemical studies showed positive reactions for keratin, CK5/6, p63, CK7, EMA, and CEA in all cases tested, while bcl-2 and CD117 were rarely positive. GFAP, MSA, TTF-1, and S100 protein were non-reactive. p53 and Ki-67 were reactive to a variable degree. MEC need to be considered in the differential diagnosis of a number of sinonasal lesions, particularly adenocarcinoma and necrotizing sialometaplasia. The patients were separated into stage I (n = 9), stage II (n = 6), and stage III (n = 4), without any patients in stage IV at presentation. Surgery occasionally accompanied by radiation therapy (n = 2) was generally employed. Six patients developed a recurrence, with 5 patients dying with disease (mean, 2.4 years), while 14 patients are either alive (n = 9) or had died (n = 5) of unrelated causes (mean, 14.6 years). MEC probably arises from the minor mucoserous glands of the upper aerodigestive tract, usually presenting in patients in middle age with a mass. Most patients present with low stage disease (stage I and II), although invasive growth is common. Recurrences develop in about a third of patients, who experience a shorter survival (mean, 6.5 years). The following parameters, when present, suggest an increased incidence of recurrence or dying with disease: size ≥4.0 cm (P = 0.034), high mitotic count (P = 0.041), atypical mitoses (P = 0.007), mixed anatomic site (P = 0.032), development of recurrence (P = 0.041), high tumor grade (P = 0.007), and higher stage disease (P = 0.027).
PMCID: PMC3370018  PMID: 22183767
Sinonasal tract; Mucoepidermoid carcinoma; Nasal cavity; Maxillary sinus, ethmoid sinus; Frontal sinus; Review; Meta-analysis; Immunohistochemistry; Prognosis; Outcome; Staging; Differential diagnosis; Carcinoma
10.  Practice patterns regarding noninvasive rhinosinusitis in the immunosuppressed patient population 
Allergy & Rhinology  2013;4(3):e151-e154.
The number of immunosuppressed patients is growing remarkably. Currently, there is no guideline on how treatment of noninvasive sinusitis in these patients may differ from that of the general population, and practice patterns vary widely across the country. The purpose of this survey was to examine practice patterns and management for this patient population. A survey and literature review were performed. The survey was sent to the membership list serve of the American Rhinologic Society. Twelve questions were asked. Four demographic questions were asked about the physicians and their practices. Four questions were asked about the type of immunocompromised patients they saw. Two questions were asked about management in the setting of significant acute and chronic sinusitis. The responses were collected and analyzed using Pearson independent chi-square testing. Of 871 members on the list serve only 89 physicians responded. The majority of responders were sinus and skull base surgeons practicing in an academic setting. There was a large range of geographic location, years in practice, and patient population. Two significant findings related years in practice to management of chronic sinus immunocompromised patients (p = 0.012) and correlated the choice of management option in acute and chronic sinus immunocompromised patients (p = 0.006). There is no standardized method of treating the vulnerable patient population of immunocompromised patients with noninvasive acute and chronic sinusitis and this survey shows the wide range of practice. Clinical research is needed to standardize and optimize treatment for these patients.
PMCID: PMC3911804  PMID: 24498520
Acute; chronic; immunocompromised; immunodeficiency; immunosuppressed; management; medical therapy; rhinosinusitis; sinusitis; surgical therapy; treatment
11.  An endonasal approach to the resection of a papillary seromucinous adenocarcinoma of the Eustacian tube 
Papillary seromucinous adenocarcinoma of the sinonasal tract is exceedingly rare. The objectives of this case report are to describe a case of papillary seromucinous adenocarcinoma presenting in the nasopharynx and to review the literature pertaining to other similar cases.
A review of the patient's chart and a review of the English literature were conducted.
We describe the case of a 64 year-old woman who presented with a 3-year history of epistaxis and right-sided otitis media with effusion. The patient had been followed for a known nasopharyngeal mass that had twice been biopsied and in both cases was considered a benign mass pathologically. A third biopsy was diagnosed as a low-grade papillary seromucinous adenocarcinoma. The patient was otherwise asymptomatic. The patient was referred to a multidisciplinary cancer clinic at which endoscopic resection was determined to be the preferred treatment modality. A literature review and approach to patients with nasopharyngeal masses will be presented.
Papillary seromucinous adenocarcinoma is a rare tumor that can present in the nasopharynx. We describe the endoscopic surgical management of one such patient that presented to our care.
PMCID: PMC3650951  PMID: 23663512
Nasopharynx; Seromucinous adenocarcinoma; Endoscopic resection; Eustacian tube
12.  Blastomyces Antigen Detection for Monitoring Progression of Blastomycosis in a Pregnant Adolescent 
Although disseminated blastomycosis is a rare complication in pregnancy, delay in diagnosis and treatment can be fatal. We investigate the use of the Blastomyces urine antigen in diagnosis following disease progression in the intrapartum, postpartum, and neonatal periods. We describe a case of disseminated blastomycosis in a pregnant adolescent and review the pertinent literature regarding treatment and monitoring blastomycosis in pregnancy and the neonatal periods. This is the first reported case in which the Blastomyces urine antigen is utilized as a method of following disease activity during pregnancy confirming absence of clinically evident disease in a neonate. Urine antigen detection for blastomycosis can be useful for following progression of disease in patients with disseminated blastomycosis in both the intrapartum and postpartum periods.
PMCID: PMC1906866  PMID: 17641724
13.  Endoscopic management of posterior epistaxis: a review 
The paradigm for the management of epistaxis, specifically posterior epistaxis, has undergone significant changes in the recent past. Recent prospective and retrospective data has shown that the endonasal surgical management of posterior epistaxis is superior to posterior nasal packing and angiography/embolization with regards to various factors including pain, cost-effectiveness, risk and overall control of bleeding. Endonasal endoscopic surgical techniques for posterior epistaxis include direct cauterization and transnasal endoscopic sphenopalatine/ posterior nasal artery ligation or cauterization with or without control of the anterior ethmoidal artery. Despite the evidence provided by the current literature, a universal treatment protocol has not yet been established. This review article provides an up-to-date assessment of the available literature, and presents a structured paradigm for the management of posterior epistaxis.
PMCID: PMC3970224
Epistaxis; Endoscopic sphenopalatine artery ligation; Posterior epistaxis; Sphenopalatine artery
14.  Association between allergic rhinitis and asthma in a Northern Alberta cohort 
Many published epidemiologic studies confirm a marked increase in the prevalence of asthma and allergic rhinitis. The link between allergic rhinitis and asthma has been extensively studied and approximately 75% of patients with asthma have allergic rhinitis. The proportion of patients with asthma in populations of allergic rhinitis patients has not been well studied.
The purpose of this study is to estimate the prevalence of undiagnosed asthma in a specific population of patients presenting to an Otolaryngologist with symptoms of allergic rhinitis.
Study design
Prospective cohort study. Methods: Patients presenting with symptoms of allergic rhinitis to two tertiary care Rhinology practices in Northern Alberta were asked to undergo allergy skin testing, serum IgE quantification, and pulmonary functional testing. Patients with previous asthma screening or known history of reactive airway disease or asthma were excluded.
107 patients with allergic rhinitis symptoms were recruited between September 2010 to January 2013. Patients predominantly had perennial or persistent rhinitis (64.5%) with moderate-severe symptoms (50.5%). While only 14.9% of patients had abnormal IgE levels, 68.8% had positive skin testing. Abnormal pulmonary function tests were obtained in 39.1% of patients and 26.1% of patients were diagnosed with asthma.
There is a high prevalence of undiagnosed asthma in patients presenting to tertiary Rhinology care with moderate to severe allergic rhinitis symptoms. Screening lung function testing should be considered in this patient population.
PMCID: PMC3895780  PMID: 24350985
15.  Orbital Cellulitis: A Rare Presentation of Metastatic Bronchial Carcinoma 
Case Reports in Otolaryngology  2011;2011:397451.
Objective. We report a rare and unusual case of bronchial carcinoma presenting with symptoms of complications of sinonasal disease. Case Report. A 66-year-old lady was referred with a 1-week history of progressive ocular pain, chemosis, and visual disturbance. Computed tomography of the paranasal sinuses revealed frontal and ethmoidal sinus opacification with orbital involvement consistent with a diagnosis of orbital cellulitis secondary to sinusitis. Surgical exploration revealed that the sinuses and right orbit were filled with soft tissue and subsequent histopathological examination of the biopsies indicating metastases from an adenosquamous bronchial carcinoma. Further imaging revealed a large, asymptomatic, bronchial primary with deposits in the brain and liver. The advanced presentation of the disease limited treatment to best supportive care. Conclusion. Orbital cellulitis and sinonasal malignancies have a similar pattern of clinical presentation, posing a potential diagnostic pitfall. There are only two previously reported cases of metastatic lung carcinoma in the frontal sinus with 15 cases of sinonasal tract involvement reported overall. There are no reported cases of adenosquamous carcinoma in the sinonasal tract.
PMCID: PMC3420758  PMID: 22937366
16.  Asthma and Allergic Diseases in Pregnancy A Review 
Asthma and allergic disorders can affect the course and outcome of pregnancy. Pregnancy itself may also affect the course of asthma and related diseases. Optimal management of these disorders during pregnancy is vital to ensure the welfare of the mother and the baby.
Specific pharmacological agents for treatment of asthma or allergic diseases must be cautiously selected and are discussed here with respect to safety considerations in pregnancy. Although most drugs do not harm the fetus, this knowledge is incomplete. Any drug may carry a small risk that must be balanced against the benefits of keeping the mother and baby healthy. The goals and principles of management for acute and chronic asthma, rhinitis, and dermatologic disorders are the same during pregnancy as those for asthma in the general population.
Diagnosis of allergy during pregnancy should mainly consist of the patient’s history and in vitro testing.
The assured and well-evaluated risk factors revealed for sensitization in mother and child are very limited, to date, and include alcohol consumption, exposure to tobacco smoke, maternal diet and diet of the newborn, drug usage, and insufficient exposure to environmental bacteria. Consequently, the recommendations for primary and secondary preventive measures are also very limited in number and verification.
PMCID: PMC2999828  PMID: 21151812
allergy; atopy; newborn; pregnancy; prevention
17.  Current and future applications of the anti-IgE antibody omalizumab 
Biologics : Targets & Therapy  2008;2(1):67-73.
IgE antibodies are a pivotal factor in pathophysiology of allergic diseases, and the possibility of reducing their level by anti-IgE has long been envisioned. Following several attempts, an effective biologic agent was obtained with the recombinant humanized mono-clonal antibody (rhuMAb)-E25, known as omalizumab. A number of controlled clinical trials demonstrated its efficacy and safety in the treatment of severe allergic asthma uncontrolled by standard drug treatment with maximal recommended doses, and treatment with omalizumab is currently included in international guidelines on asthma management. Other studies reported a clear effectiveness also in allergic rhinitis, but the cost of the anti-IgE treatment suggests its use in patients with rhinitis concomitant with asthma. Other indications to be further investigated are skin disorders such as atopic dermatitis and IgE-mediated urticaria, as well as adverse reactions to foods, with a particularly important role in preventing food-induced anaphylaxis. Finally, there are data indicating the usefulness of omalizumab when used in combination with allergen specific immunotherapy, in terms of reducing the adverse reactions to treatment and increasing the clinical efficacy.
PMCID: PMC2727776  PMID: 19707429
IgE; anti-IgE; omalizumab; allergic asthma; allergic rhinitis; atopic dermatitis; food allergy; allergen immunotherapy
18.  Asthma and Allergic Diseases in Pregnancy: A Review 
Asthma and allergic disorders can affect the course and outcome of pregnancy. Pregnancy itself may also affect the course of asthma and related diseases. Optimal management of these disorders during pregnancy is vital to ensure the welfare of the mother and the baby.
Specific pharmacological agents for treatment of asthma or allergic diseases must be cautiously selected and are discussed here with respect to safety considerations in pregnancy. Although most drugs do not harm the fetus, this knowledge is incomplete. Any drug may carry a small risk that must be balanced against the benefits of keeping the mother and baby healthy. The goals and principles of management for acute and chronic asthma, rhinitis, and dermatologic disorders are the same during pregnancy as those for asthma in the general population.
Diagnosis of allergy during pregnancy should mainly consist of the patient's history and in vitro testing.
The assured and well-evaluated risk factors revealed for sensitization in mother and child are very limited, to date, and include alcohol consumption, exposure to tobacco smoke, maternal diet and diet of the newborn, drug usage, and insufficient exposure to environmental bacteria. Consequently, the recommendations for primary and secondary preventive measures are also very limited in number and verification.
PMCID: PMC2999828  PMID: 21151812
allergy; atopy; newborn; pregnancy; prevention
19.  Metastatic Renal Cell Carcinoma to the Sinonasal Cavity: A Case Series 
Objectives To describe the presentation, work-up, and management of patients with metastatic renal cell carcinoma (RCC) to the sinonasal cavity and skull base, and to describe our current treatment algorithm of endoscopic surgical resection followed by radiation therapy.
Design Retrospective review of two recent cases from our institution over a 1-year period, with a relevant review of the literature.
Setting A large regional tertiary care facility.
Participants Consecutive cases of RCC with metastases to the sinonasal cavity presenting to our institution.
Main Outcome Measures Preoperative and postoperative sinonasal outcome test (SNOT)-22 scores, duration of hospital stay, complications, and local disease control
Results Patients in this series underwent preoperative embolization followed by endoscopic resection without complication. Postoperatively they were treated with radiation therapy. They experienced improvement in their SNOT-22 scores and are currently free of local disease.
Conclusion Metastatic RCC to the sinonasal cavity can be safely treated with preoperative embolization followed by endoscopic surgical resection and radiation therapy, which can result in improvement in sinonasal quality of life and is a potential adjunct for local control of disease.
PMCID: PMC3836888  PMID: 24294563
renal cell carcinoma; quality of life; embolization; epistaxis; nasal obstruction
20.  Clinical study of headache in relation to sinusitis and its management 
Journal of Medicine and Life  2013;6(4):389-394.
Aim: To study relation of headache with sinusitis and its management. Methodology: Patients clinically presenting with headache were selected. Only patients with headache due to rhinogenic causes were subjected to X-ray paranasal sinuses and diagnostic nasal endoscopy and followed-up to evaluate management. Results: Majority of the patients were of age group 21-30 years and it is more predominant in males. Majority of the patients of headache were having DNS (28.9%), acute sinusitis (28.9%), osteomeatal complex disease (24.63%) and few number of patients had nasal polyp (8.69%), allergic rhinitis (5.79%) and rarely patients had atrophic rhinitis (2.89%). Headache was localized in forehead (43.4%), more than one site (34.7%) in majority of cases and few number of patients had headache at glabella (13.04%) and top of head (8.69%). Majority of the patients who underwent antral washout were not relieved, so they underwent functional endoscopic sinus surgery, which gave dramatic results in improving symptoms of patients including headache. Conclusions: Headache is nearly a universal human experience. The lifetime incidence of headache is estimated to be at least 90%. To know whether the headache is sinogenic or not; firstly the patient is clinically assessed, then radiological investigations (X-ray PNS) are done. Role of FESS is huge and ultimately it is it that is the cure for the headache due to rhinogenic causes. Abbreviations: DNE - Diagnostic nasal endoscopy, FESS - Functional endoscopic sinus surgery, PNS - Paranasal sinuses
PMCID: PMC3973877
Headache; Sinusitis; FES
21.  The Role of EGFR and HER2- Activating Mutations in Maxillary Sinus Cancer 
Mædica  2012;7(1):70-74.
Head and neck cancers account for less than 5% of all cancers worldwide and for less than 1% of all cancer deaths in Romania. Sinonasal squamous cell carcinomas are malignant tumors with origin in the respiratory mucosa of the paranasal sinuses and the nasal cavity. Because of the proximity to different important structures such as the brain, the eye the relevance of a multimodal therapy is well known. We take into discussion not only the most recent data from novel agents targeting EGF receptor (EGFR), VEGF and p53 pathways for the management of sinonasal cancer, but also further development of multimodal approach, and the use of biomarkers to appreciate the progression of the disease and the prognostic and overall survival rate in clinical practice. EGFR alterations have been implicated in the pathogenesis and progression of many malignancies. EGFR overexpression has been studied extensively regarding its clinical use but the results are yet to be analyzed.
PMCID: PMC3484801  PMID: 23118824
head and neck cancers; sinonasal cancer; EGFR; overexpression
22.  A rare case of breast cancer metastasising to the nasopharynx and paranasal sinuses 
Metastatic spread from non-head and neck tumours to the sinonasal region is exceedingly rare. We present a case of breast cancer metastasis to the nasopharynx, ethmoid and sphenoid sinuses. To date there have been only two similar cases in the literature. We discuss the diagnosis and management of such cases and propose how they may be staged.
A 75-year-old woman with past medical history of breast carcinoma, presented clinically as having a primary sinonasal malignancy. Magnetic resonance imaging (MRI) demonstrated a lesion involving the spenoid and ethmoid sinuses, nasendoscopy revealed a mass in the nasopharynx. Biopsy from clinic pointed to inverted sinonasal papilloma, however this did not fit with the MRI or the clinical picture. Repeat biopsy under image guidance revealed the lesion to be a breast cancer metastasis.
An extensive literature review revealed few cases of spread to the sinonasal region from distant primary malignancy. When such cases do arise, most are from renal tumours. Breast cancer metastases usually present with signs and symptoms of disseminated disease, however our case represents a true isolated metastasis. We discuss the management of our case and suggest the use of the tumour-node-metastasis (TNM) system, in order to stage these rare isolated occurrences.
If discovered early, this rare manifestation may be managed by primary surgical resection. Metastases to the region may be more common than previously thought. A high index of suspicion should be employed, especially where there is past medical history of malignancy.
PMCID: PMC3397298  PMID: 22743009
Breast cancer; Breast neoplasms; Metastases; Nasopharynx; Naopharyngeal neoplasms
23.  Sinonasal inhalation of tobramycin vibrating aerosol in cystic fibrosis patients with upper airway Pseudomonas aeruginosa colonization: results of a randomized, double-blind, placebo-controlled pilot study 
In cystic fibrosis (CF), the paranasal sinuses are sites of first and persistent colonization by pathogens such as Pseudomonas aeruginosa. Pathogens subsequently descend to the lower airways, with P. aeruginosa remaining the primary cause of premature death in patients with the inherited disease. Unlike conventional aerosols, vibrating aerosols applied with the PARI Sinus™ nebulizer deposit drugs into the paranasal sinuses. This trial assessed the effects of vibrating sinonasal inhalation of the antibiotic tobramycin in CF patients positive for P. aeruginosa in nasal lavage.
To evaluate the effects of sinonasal inhalation of tobramycin on P. aeruginosa quantification in nasal lavage; and on patient quality of life, measured with the Sino-Nasal Outcome Test (SNOT-20), and otologic and renal safety and tolerability.
Patients were randomized to inhalation of tobramycin (80 mg/2 mL) or placebo (2 mL isotonic saline) once daily (4 minutes/nostril) with the PARI Sinus™ nebulizer over 28 days, with all patients eligible for a subsequent course of open-label inhalation of tobramycin for 28 days. Nasal lavage was obtained before starting and 2 days after the end of each treatment period by rinsing each nostril with 10 mL of isotonic saline.
Nine patients participated, six initially receiving tobramycin and three placebo. Sinonasal inhalation was well tolerated, with serum tobramycin <0.5 mg/L and stable creatinine. P. aeruginosa quantity decreased in four of six (67%) patients given tobramycin, compared with zero of three given placebo (non-significant). SNOT-20 scores were significantly lower in the tobramycin than in the placebo group (P=0.033).
Sinonasal inhalation of vibrating antibiotic aerosols appears promising for reducing pathogen colonization of paranasal sinuses and for control of symptoms in patients with CF.
PMCID: PMC3930477  PMID: 24596456
PARI Sinus; nasal lavage; SNOT-20; cystic fibrosis; Pseudomonas aeruginosa; sinonasal; upper airways
24.  Non Allergic Rhinitis: Prevalence, Clinical Profile and Knowledge Gaps in Literature 
Oman Medical Journal  2011;26(6):416-420.
Although Nasal symptoms induced by Non-allergic rhinitis| (NAR) are a cause of wide spread morbidity; the disease is trivialized. There is a lack of Epidemiological studies on the prevalence of non-allergic rhinitis. In spite of being one of the commonest conditions presenting to the General practitioner and otolaryngologists, the clinical profile, diagnosis, and management outcomes are unknown. The objectives of the study were to examine the prevalence and clinical profile of non-allergic rhinitis in Oman. Secondary objective was to identify Knowledge gaps in literature with the aim of directing future research.
A cross sectional study of 610 consecutive adult patients presenting to the Ear, Nose and Throat clinic at Sultan Qaboos University Hospital is presented in this paper. The diagnosis of NAR was mainly based on step wise fashion; including a thorough clinical history and exclusion of other causes of rhinitis; all consecutive patients diagnosed with rhinitis (n=113) had a detailed history, nasal endoscopy, nasal smears, CT scans and an antihistamine response trial. The prevalence of NAR with its clinical profile was subsequently determined. Primary research articles and meta-analysis evaluated for the knowledge gap study were identified through MEDLINE search of English language literature published between 2000-2011.
A total of 610 consecutive patients were studied. The overall prevalence of rhinitis was 18.5% (n=113). The prevalence of NAR was 7.5% (n=46). Cases of allergic rhinitis (5.7%; n=35), Chronic rhinosinusitis (1.8%; n=11), and miscellaneous causes (3.4%; n=21) were excluded. Among the rhinitis population (n=113), the prevalence of NAR was 57% (n=46). The major presenting symptoms included nasal obstruction (93%; n=43), postnasal drainage (78%; n=36), and rhinorrhea (62%; n=29). For the knowledge gap study; 115 Medline titles were reviewed, four systematic reviews, and 34 research papers were reviewed. The text of two recent otolaryngology text books was also reviewed, and the main results of the study revealed the prevalence of NAR had not previously been studied in Oman. Although the recent text now clearly defines NAR, there is scant literature on the prevalence, diagnosis and management outcomes of NAR in the literature.
The study found that more than half of rhinitis patients suffered from NAR. There are no specific diagnostic tests for NAR; a thorough case history is the best diagnostic tool to date. A substantial knowledge gap exists in literature with relations to pathogenesis, clinical and laboratory diagnosis, as well as in reference to medical and surgical outcomes. Larger studies are required and management outcomes need to be studied.
PMCID: PMC3251201  PMID: 22253950
Nasal obstruction; Non allergic rhinitis; Seasonal rhinitis; NANIPER; NARES; Idiopathic rhinitis
25.  Small cell neuroendocrine carcinoma of the paranasal sinus 
Small cell neuroendocrine carcinoma (SNEC) is an uncommon tumor. This tumor usually occurs in the lungs, the extra-pulmonary form accounts for only about 4% of all cases. Primary SNEC of the paranasal sinuses is extremely rare; only about 76 cases have been reported in literature. Unfortunately due to the rarity of this neoplasm, there are no specific recommendations pertaining to the management, treatment options are generally extrapolated from similar tumors of pulmonary origin. While Surgery was used in the past, upfront chemoradiation now seems to be evolving as the treatment of choice. We report a case of sinonasal SNEC who had undergone definitive concurrent chemoradiation and is currently disease-free for close to 2 years. The clinical presentation, imaging studies, histopathological diagnosis with immunohistochemistry correlation, management protocols, and a brief review of literature of this rare tumor is discussed.
PMCID: PMC3800372  PMID: 24163566
Management; paranasal sinus; prognosis; small cell neuroendocrine carcinoma

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