Transclival meningoceles and primary spontaneous cerebrospinal fluid (CSF) leaks at the clivus are extremely rare lesions and only few of them have been reported in the literature. We report here six cases of transclival primary spontaneous CSF leaks through the clivus. A retrospective case study was performed. We reviewed six cases involving sinonasal CSF leaks located at the clivus treated between 1997 and 2009. Presenting symptoms, duration of symptoms, defect size, site of defect, surgical approach and technique of defect closure, intraoperative complications, postoperative complications, and recurrences are discussed. All CSF leaks were located in the upper central part of the clivus. two of six patients showed signs of increased intracranial pressure (ICP) including arachnoid pits and/or empty sella. For three patients a purely transnasal approach was used with multilayer reconstruction using a nonvascularized graft, and three patients underwent a transnasal transseptal approach with a multilayer reconstruction, with nasoseptal flap. No recurrences of CSF leaks at clivus or other sites were observed to date with a mean follow-up of 10.3 years (range, 3–15 years). Spontaneous CSF rhinorrhea located at the clivus is an extremely rare condition. To date, only eight cases have been described. Here, we report the largest group of six consecutive cases. Irrespective of the used reconstruction technique in all cases a 100% closure rate was achieved. However, identification of increased ICP is an essential aspect and this condition should be treated either medically or surgically.
Clivus; CSF leak; expanded endonasal approach; meningocele
Although a variety of theories have been proposed about functions of the paranasal sinuses, not one is clear today. Nonetheless, paranasal sinus–related diseases are associated with a high rate of morbidities. Therefore, it is essential to identify the structure and pathophysiology of the paranasal sinuses. Computed tomography (CT) is a valuable tool displaying anatomic variations and diseases. Because paranasal sinus development is a complex and long-lasting process, there are great structural variations between individuals. Several degrees and combinations of aplasias and hypoplasias have been reported; however, there is only one case of total paranasal sinus aplasia in the literature. Here, we present the second case of total paranasal sinus aplasia. Paranasal sinus development, functions of the paranasal sinuses, and the role of CT were evaluated.
Aplasia; computed tomography; functions of the paranasal sinuses; paranasal sinus
Approximately 80% of children with asthma have coexisting allergic rhinitis. The accurate recognition and assessment of asthma and rhinitis symptoms is an integral component of guideline-based treatment for both conditions. This article describes the development and preliminary evaluation of a novel paradigm for testing the accuracy of children's assessment of their upper airway (rhinitis) symptoms. This work is guided by our previous research showing the clinical efficacy of tools to evaluate children's perceptual accuracy of asthma symptoms and linking accurate asthma symptom perception to decreased asthma morbidity (Fritz G, et al., Ethnic differences in perception of lung function: A factor in pediatric asthma disparities? Am J Respir Crit Care Med 182:12–18, 2010; Klein RB, et al., The Asthma Risk Grid: Clinical interpretation of symptom perception, Allergy Asthma Proc 251–256, 2004). The pilot study tests a paradigm that allows for the examination of the correspondence of children's assessment of their upper airway functioning with actual values of upper airway flow through the use of a portable, handheld nasal peak flowmeter. Nine children with persistent asthma were evaluated over a 4-week period. The article describes the rhinitis perceptual accuracy paradigm and reviews the results of a pilot study, showing a large proportion of inaccurate rhinitis symptoms “guesses” by the sample of children with persistent asthma. Patterns of inaccuracy, rhinitis control, and asthma morbidity are also described. Directions for future work are reviewed. The development of clinical tools to evaluate children's accuracy of rhinitis symptoms are needed, given the central role of the self-assessment of symptoms in guideline-based care. Accurate perception of the severity of rhinitis symptoms may enhance rhinitis control, lessen the burden of asthma, and prevent unnecessary emergency use among this high-risk group of children.
Allergy; asthma; children; perceptual accuracy; rhinitis; treatment; upper airway
Pannexins are a second family of gap-junction proteins in vertebrates, classified as pannexin-1, pannexin-2, and pannexin-3. Pannexin-1 is one of the candidates for channel-mediated ATP release into the extracellular space. In airway epithelia, ATP signaling modulates multiple cellular functions such as mucus/ion secretion and mucociliary clearance systems. However, the expression of pannexins in the upper airway has not been investigated. Nasal septal mucosae were collected from adult male Wistar rats aged 20–24 weeks. The expression of pannexin-1, pannexin-2, and pannexin-3 was examined by reverse transcription polymerase chain reaction (RT-PCR) and by whole-mount fluorescence immunohistochemistry. Transcripts for pannexin-1, pannexin-2, and pannexin-3 were detected in nasal septal mucosae of adult rats by RT-PCR. Distinct immunohistochemical fluorescence for pannexin-1 was observed in the epithelial layer, whereas there was no immunoreactivity for pannexin-2 or pannexin-3. This is the first article establishing the existence of pannexins (predominantly pannexin-1) in the upper airway, suggesting their possible participation in the physiological functions of ATP release and signaling in this tissue.
Immunohistochemistry; nasal mucosa; pannexin; rat; RT-PCR
This study was designed to validate a grading scheme for lateral nasal wall insufficiency with interrater and intrarater reliability measures. Representative endoscopic videos depicting varied degrees of lateral nasal wall insufficiency were collated into a 30-clip video (15 clips in duplicate). This was rated by five reviewers for a total of 150 observations. Interrater and intrarater reliability were determined using Fleiss kappa and intraclass correlation coefficient (ICC) statistics, respectively. Good agreement was established between reviewers (interrater reliability), with a Fleiss kappa of 0.7733 (p < 0.01). Analysis of intrarater variability with the ICC revealed a very strong agreement (ICC = 0.88; p < 0.01). The proposed grading system is shown to have good interrater and intrarater reliability. It provides a reliable instrument for assessing lateral wall insufficiency.
Collapse; grading; internal valve; lateral nasal wall; lateral wall; nasal valve; obstruction
Chronic rhinosinusitis (CRS) presents distinct inflammatory and remodeling patterns in different populations and environments. Tibetan ethnic groups live at high altitudes and in cold weather conditions. We sought to examine whether Tibetans exhibit distinct CRS pathology or characteristics. Sinonasal polyps and mucosal tissue were obtained from 14 Tibetan patients with CRS and nasal polyps (CRSwNPs), 13 patients with CRS without nasal polyps (CRSsNPs), and 12 Tibetan controls. Tissue homogenates and serum samples were assayed for several T-helper (TH) cell cytokines and mediators using enzyme linked immunosorbent assay profiles were measured using quantity polymerase chain reaction. Several key inflammatory cells were examined for immunohistochemical markers. CRSwNPs were characterized by increased mediator promoting eosinophilic inflammation (interleukin [IL]-5, eosinophil cationic protein, and total immunoglobulin E) and slight synergism with expression of IL-8, IL-2sRa, IL-1beta, IL-6, and myeloperoxidase, and a predominance of eosinophils, mast cells, and neutrophils. GATA-3 transcription factor was significantly increased and Foxp3 showed a tendency to be impaired in CRSwNPs compared with controls. CRSsNPs were characterized by significantly high levels of transforming growth factor beta1, increased interferon γ, and a significant enhancement of Foxp3 and T-beta compared with CRSwNPs. There were reduced numbers of inflammatory cells but increased levels of macrophages in CRSsNPs. Compared with CRSsNPs, CRSwNPs present a severe inflammatory reaction and show a TH2 milieu with apparently impaired regulatory T cells (Treg) function and increased inflammatory cells infiltration predominated by eosinophilic and mast cells. In contrast, TH1 polarization with enhanced Treg function and increased levels of macrophages appear in CRSsNPs.
Chronic rhinosinusitis; eosinophils; high altitude; interleukin-5; nasal polyps; neutrophils; T-cell subsets; Tibetan patients; transcription factor
Allergic rhinitis (AR) may be cured by allergen immunotherapy (AIT). However, patient characteristics for prescribing AIT are not well defined. This study aimed at evaluating the patient's profile to be a candidate for AIT in a cohort of patients suffering from AR, evaluated in 20 Italian Allergy or Ear, Nose, and Throat Centers. The study has been performed on 198 patients (98 men; mean age, 26.8 years) with AR (assessed by Allergic Rhinitis and Its Impact on Asthma [ARIA] criteria). The kind and the number of prescribed allergen extracts, type of diagnosis, severity of symptoms, and patient's perception of symptoms and drug use were evaluated. Patients were subdivided in AIT-treated and without AIT (as controls) subgroups. Most of the patients (69.7%) had persistent AR with moderate–severe symptoms. The mean number of sensitization was 3.4. ARIA classification and sensitization number did not affect AIT choice, but the type of allergen was relevant. AIT-treated patients had milder symptoms than controls if assessed by doctors, but AIT patients perceived more severe symptoms and larger drug use than controls. This study shows that the choice of AIT is based on patient's perception and type of allergen, but number of sensitizations, symptom severity assessed by doctors, and ARIA classification are not relevant factors. The key message might be that it is always relevant to pay attention to the complaints referred by the patient.
Allergen immunotherapy; allergic rhinitis; patient's perception; polysensitization
For chronic sinusitis surgery, the Draf III approach provides a common median drainage pathway for bilateral frontal sinuses from orbit to orbit. The Draf IIb provides unilateral drainage from orbit to septum. In several cases, inclusion of the nasal and frontal sinus septum in a Draf IIb was advantageous without extension to the opposite frontal recess. The proposed nomenclature is Draf IIc. This study was designed to (1) develop a surgical option for chronic frontal sinusitis where access to one frontal recess is limited or unnecessary and (2) minimize unnecessary surgical manipulation of uninvolved areas. Revision endoscopic frontal sinus surgery was performed on two patients with persistent frontal sinus opacification. Surgery crossed midline including one frontal recess with resection of the superior nasal septum. The surgical result was assessed on endoscopy and computed tomography (CT). The postoperative course was unremarkable with relief of frontal pressure. Postoperative CT scan showed well-aerated frontal sinuses with a widely patent common drainage pathway. Postoperative nasal endoscopy revealed normal mucosa with no exposed bone or edema. The Draf IIc extends the Draf IIb across the midline, without including the opposite frontal recess. This can be accomplished most easily using an interfrontal sinus septal cell or an eccentric interfrontal sinus septum. The Draf IIc is a surgical option in cases of chronic or recalcitrant frontal sinus diseases, including unilateral or bilateral obstruction, where access to the ipsilateral frontal recess is limited or favorable anatomy allows drainage with reduced manipulation of an uninvolved side.
Chronic frontal sinusitis; Draf procedures; endoscopic frontal sinus surgery; frontal central cell; frontal intersinus septal cell; frontal intersinus septectomy; frontal intersinus takedown procedure; frontal sinus; frontal sinusitis; functional endoscopic sinus surgery; modified endoscopic Lothrop procedure
The safety of shared specific vaccines (SSVs) has been questioned by some experts. The purpose of this study was to evaluate the safety of SSVs. Details of systemic allergic reactions after subcutaneous immunotherapy injections were captured on a standardized form from July 2005 to July 2010. Patient records were evaluated for factors that might be associated with increased rate of systemic reactions and, in addition, were examined for any errors. Systemic reaction rates (SRRs) using a combination of shared and patient-specific vaccines (PSVs) were similar to previously reported studies (0.23 reactions per 100 shots). There were no systemic reactions resulting from errors where the incorrect shared allergen was administered, but we did note one reaction after an erroneously administered PSV. There were two dosage errors associated with both shared and patient-specific immunotherapy. Most reactions were mild to moderate (World Allergy Organization grade, 1 or 2). Severe reactions with 911 activations were noted in six patients. Thirty percent of reactions occurred out of the office and the average time to reaction was 48 minutes. Epinephrine was administered in only 60% of patients. Epicutaneous reactivity to mites, cats, dogs, and pollen but not mold occurred significantly more in reactors. Differences in SRRs were encountered between satellite offices. Using a combination of SSV and PSV, SRRs were similar to previously reported studies; moreover, no systemic reactions occurred where a SSV was erroneously administered. SRR surveillance is a useful safety tool.
Anaphylaxis; immunotherapy; safety; shared specific; study; subcutaneous injections; systemic reactions
Multiple systemic diseases produce various clinical manifestations in the sinonasal area. They usually appear as difficult-to-diagnose disease processes with slow, atypical clinical courses. The aim of this study was to evaluate the sinonasal manifestations of systemic vasculitides, highlighting key points for diagnosis and differential diagnosis with other pathological entities, especially cocaine-induced midline destructive lesions (CIMDL). A retrospective study was performed of 10 patients treated in our hospital during the last 5 years with an initial diagnosis of systemic vasculitides with sinonasal involvement: eight patients with granulomatosis with polyangiitis (GPA; new nomenclature for Wegener granulomatosis) and two patients with Churg-Strauss syndrome (CSS). The study variables were clinical presentation, nasal endoscopy results, maxillofacial scan results, nasal biopsy results, erythrocyte sedimentation rate, and autoimmune antibody levels. The definitive diagnosis was GPA in six (60%) patients, CSS in two (20%) patients, and CIMDL in two (20%) patients. Nasal symptoms were similar in all patients, but nasal polyps were present in only one patient with CSS. Systemic manifestations were absent in patients with CIMDL. Likewise, peripheral eosinophilia was observed only in the two patients with CSS. Specific positive biopsy specimens were obtained in six patients (all six patients with GPA, one with CSS, and one with CIMDL). Antineutrophil cytoplasmic antibodies (ANCA) were positive in all patients with GPA (proteinase 3 antigen in five patients and myeloperoxidase in one patient), and perinuclear ANCA was positive in one patient with CIMDL; however, this patient showed an undefined pattern. Finally, the response to treatment was adequate in all patients excluding those with CIMDL. GPA and CIMDL syndromes pose a difficult differential diagnosis because they have common clinical, serological, and histological presentations. Negative histological results do not exclude the diagnosis of sinonasal vasculitides. The absence of systemic manifestations and the lack of response to treatment will lead to the confirmation of CIMDL syndrome in a cocaine user. Otolaryngologists play an important role in the early and differential diagnosis of these diseases.
ANCA; autoimmune antibodies; Churg-Strauss syndrome; cocaine user; eosinophilia; differential diagnosis; histological diagnosis; nasal polyps; systemic diseases; Wegener's granulomatosis
The study of nasal ciliary beat frequency (CBF) and ultrastructure may contribute to the understanding of pathognomonic cases of male infertility associated with defects in sperm motility. This study was designed to report a particular case of male infertility, characterized by the association of two respiratory autosomal recessive genetic diseases (alpha-1-antitrypsin deficiency [AAT-D] and primary ciliary dyskinesia [PCD]). A 39-year-old patient with complete sperm immotility, AAT-D, and bronchiectasis was studied in the Laboratory of Male Fertility, the Department of Urology, the Respiratory Center of a Pediatric Hospital, and in the Department of Clinical Medicine of a Rehabilitation Respiratory Hospital. Family history, physical examination, hormonal analysis, microbial assays, semen analysis, nasal ciliary function, and structure study by digital high-speed video photography and transmission electron microscopy are described. A noninvasive nasal biopsy to retrieve ciliated epithelium lining the inferior surface of the inferior nasal turbinates was performed and CBF was determined. Beat pattern was slightly curved and rigid, not wide, and metacronic in all the observed fields analyzed. CBF was 8.2 Hz in average (reference value, 10–15 Hz) Ultrastructural assay revealed absence of the inner dynein arms in 97% of the cilia observed. The final infertility accurate diagnosis was achieved by the study of nasal CBF and ultrastructure contributing to the patient health management and genetic counseling while deciding fatherhood. Beyond this particular case, the present report may open a new field of studies in male infertility, mainly in cases of asthenozoospermia.
alpha-1-antitrypsin deficiency; bronchiectasis; case report; ciliary dyskinesia; digital high-speed video photography; fatherhood; genetic counseling; ICSI; male infertility; sperm motility
Sinonasal malignant neoplasms comprise only 3% of all head and neck malignancies. Synchronous and metachronous tumors of the head and neck have been described, but rarely have there been reports of a single tumor with two distinct histologies. Here, we describe a case of a sinonasal malignant neoplasm with two distinct histologies. A case report and literature review was performed. We present a case of paranasal sinus neoplasm involving two malignant cell types. An 83-year-old woman presented with a 2-year history of symptoms suggestive of chronic sinusitis, which included nasal congestion and intermittent midface pressure. More recently, her symptoms progressed with the development of left-side epistaxis and she was found to have a mass in the left maxillary and ethmoid regions. A biopsy of the maxillary sinus mass revealed a moderately differentiated squamous cell carcinoma (SCC). She underwent complete resection of the lesion through an extended endoscopic approach. Final pathological analysis showed a malignant neoplasm with two distinct malignant morphologies; a moderately differentiated SCC and small cell neuroendocrine carcinoma. Appropriate diagnosis and treatment of head and neck malignancy depends on accurate tumor classification and staging. We present a case of a sinonasal tumor with two distinct malignant entities and review the available literature on the subject. Additionally, we discuss the etiologic theories and challenges in planning the optimal approach to management in this scenario.
Azzopardi; colliding; histology; paranasal; sinus; treatment; tumor
Management of inferior turbinate hypertrophy includes surgical options in case of failure with medical treatment and the main goal of turbinate surgery is to relieve the patient's symptoms of chronic nasal congestion while preserving mucosal surfaces with reduction of the submucosal and bony tissue. In this regard, radiofrequency volumetric tissue reduction has been a thermal technique associated with satisfactory results and fewer side effects. Historical detail on onset, timing, duration, and severity of symptoms and aggravating and relieving factors are important in the differential diagnosis of postnasal drip (PND). Here, we report development of intractable PND due to inferior turbinate perforation after radiofrequency turbinate surgery for the first time in the literature and the successful improvement via removal of pathological anatomic structure under nasal endoscopy–directed surgery in a 35-year-old female patient. The patient had a good functional outcome postoperatively with no further complications or signs of recurrence occurring, to date, within a postoperative follow-up period of 1 year.
Complication; differential diagnosis; endoscopy; inferior turbinate hypertrophy; inferior turbinate perforation; nasal obstruction; postnasal drip; postseptorinoplasty; postturbinoplasty; radiofrequency turbinate surgery
Resection of a juvenile nasopharyngeal angiofibroma (JNA) is challenging because of high intraoperative blood loss secondary to the tumor's well-developed vascularity. Endoscopic sinus and skull base surgeons commonly collaborate with neurointerventionalists to embolize these tumors before resection in an attempt to reduce the vascular supply and intraoperative bleeding. However, angioembolization can be associated with significant complications. Geometric alopecia from angioembolization of JNA has not been previously reported in the otolaryngologic literature. In this study, we discuss geometric alopecia from radiation exposure during preoperative angioembolization of a JNA.
Alopecia; angioembolization; endoscopic endonasal approach; endoscopic skull base surgery; geometric alopecia; JNA; juvenile nasopharyngeal angiofibroma; pediatric sinonasal tumor; skull base; skull base tumor
Stevens-Johnson syndrome (SJS) is a debilitating condition involving the skin and mucous membranes. It is commonly the result of adverse drug reactions but can also be caused by infections. A predisposition to recurrent viral infections, such as in the case of natural killer (NK) cell dysfunction, may manifest with virally induced SJS. We present this case to suggest a possible association between NK cell dysfunction and recurrent SJS. An 11-year-old girl presents with recurring erythema, erosion, and ulceration of oral and vaginal mucosa. Small fluid-filled bumps would appear, leading to blistering and later sloughing of mucosal tissue, and bleeding would ensue. Seven separate episodes have occurred over an 8-year period, with each episode being preceded by symptoms of an upper respiratory infection. NK cell function assays were performed and NK cell phenotyping was ordered. NK cell assays showed decreased NK cell cytotoxicity at all ratios of K562 target cells. NK cell surface expression evaluation showed an immature phenotype but normal overall numbers of NK cells. NK cells are a pivotal part of the innate immune system, and, among other things, provide defense of viral infection. This case represents the manifestation of recurrent SJS as a result the lack of protection from viral illness, usually provided by NK cells in the healthy immune system.
Association; dysfunction; natural killer cell; patient; pediatric; recurrent; Stevens-Johnson syndrome
Advances in endoscopic skull base (SB) surgery have led to the resection of increasingly larger cranial base lesions, resulting in large SB defects. These defects have initially led to increased postoperative cerebrospinal fluid (CSF) leaks. The development of the vascularized pedicled nasoseptal flap (PNSF) has successfully reduced postoperative CSF leaks. Mucocele formation, however, has been reported as a complication of this technique. In this study, we analyze the incidence of mucocele formation after repair of SB defects using a PNSF. A retrospective review was performed from December 2008 to December 2011 to identify patients who underwent PNSF reconstruction for large ventral SB defects. Demographic data, defect site, incidence of postoperative CSF leaks, and rate of mucocele formation were collected. Seventy patients undergoing PNSF repair of SB defects were identified. No postoperative mucocele formation was noted at an average radiological follow-up of 11.7 months (range, 3–36.9 months) and clinical follow-up of 13.8 months (range, 3–38.9 months), making the overall mucocele rate 0%. The postoperative CSF leak rate was 2.9%. Proper closure of SB defects is crucial to prevent CSF leaks. The PNSF is an efficient technique for these repairs. Although this flap may carry an inherent risk of mucocele formation when placed over mucosalized bone during repair, we found that meticulous and strategic removal of mucosa from the site of flap placement resulted in a 0% incidence of postoperative mucocele formation in our cohort.
Anterior skull base defect; anterior skull base floor; endoscopic endonasal approach; endoscopic skull base surgery; expanded skull base approaches; mucocele; mucosal denuding; vascularized pedicled nasoseptal flap
Allergic fungal sinusitis (AFS), also referred to as allergic fungal rhinosinusitis (AFRS), is a noninvasive, eosinophilic form of recurrent chronic allergic hypertrophic rhinosinusitis. AFS has distinct clinical, histopathological, and prognostic findings that differentiate it from other forms of sinusitis. The core pathogenesis and optimum treatment strategies remain debated. Concerns surround the use of immunotherapy for AFS because allergen-specific immunoglobulin G (IgG) induced by immunotherapy could theoretically incite a Gell and Coombs type III (complex mediated) reaction. Type I hypersensitivity is established by high serum levels of allergen-specific IgE to various fungal antigens and positive Bipolaris skin test results. Type III hypersensitivity is established by an IgG-mediated process defined by the presence of allergen-specific IgG that forms complexes with fungal antigen inducing an immunologic inflammatory response. These reveal the multiple immunologic pathways through which AFS can impact host responses. Recent literature establishing benefits of fungal immunotherapy and no evidence of type III–mediated reactions, severe local reactions, or delayed reactions, indicate that application of AFS desensitization is a reasonable therapeutic strategy for this difficult to manage entity. Our review should encourage further clinical acceptance of AFS desensitization because the existing literature on this subject shows benefits of fungal immunotherapy and no evidence of type III–mediated reactions, severe local reactions, or delayed reactions.
Allergic fungal sinusitis; chronic rhinosinusitis; eosinophilic mucus; literature review
Treatment of frontal sinus disease represents one of the most challenging aspects of endoscopic sinus surgery. Frontal sinus mucocele drainage may be an exception to the rule because in many instances, the expansion of the mucocele widens the frontal sinus recess and renders surgical drainage technically undemanding. Recently, there has been an increased interest in in-office procedures in otolaryngology because of patient satisfaction and substantial savings of time and cost for both patients and physicians. Similarly, the past few years have witnessed an increased use of balloon dilation devices in sinus surgery. Previously, we have described the in-office use of this device in treating patients who failed prior conventional frontal sinusotomy in the operating room. In this report, we describe our step-by-step in-office experience using this tool for drainage of a large frontal sinus mucocele.
Balloon dilation; balloon sinuplasty; endoscopic sinus surgery; frontal sinus; frontal sinusitis; frontal sinus mucocele; frontal sinusotomy; frontoethmoidal mucocele; in-office procedure; in-office rhinology
Postoperative cerebrospinal fluid (CSF) rhinorrhea after septoplasty is a known entity resulting from errors in surgical technique and improper handling of the perpendicular plate of the ethmoid bone. When these occur, urgent management is necessary to prevent deleterious sequelae such as meningitis, intracranial abscess, and pneumocephalus. Encephaloceles are rare occurrences characterized by herniation of intracranial contents through a skull base defect that can predispose patients to CSF rhinorrhea. In this report, we present a case of CSF rhinorrhea occurring 2 weeks after septoplasty likely from manipulation of an occult anterior skull base encephalocele. To our knowledge, no previous similar case has been reported in the literature. Otolaryngologists should be aware of the possibility of occult encephaloceles while performing septoplasties because minimal manipulation of these entities may potentially result in postoperative CSF leakage.
Anterior skull base defect; anterior skull base encephalocele; cerebrospinal fluid leakage; cribriform defect; CSF leak; encephalocele; septoplasty complications
Corticosteroids are the mainstay of treatment for refractory chronic rhinosinusitis. The off-label use of steroid-eluting stents has increasingly gained popularity in functional endoscopic sinus surgery for decreasing postoperative inflammation and synechiae formation. However, there is a paucity of data outlining the safety profile of this device despite its widespread use. This study was designed to report a newly described complication of retained drug-eluting stents from endoscopic sinus surgery for refractory rhinosinusitis. This report highlights a potential risk of the drug-eluting stent in the treatment of recalcitrant rhinosinusitis and the need for further clinical investigations whenever a novel medical device becomes available on the market.
chronic; complication; corticosteroid; drug eluting; endoscopic sinus surgery; inflammation; polyposis; rhinosinusitis; sinusitis; stent
Preoperative recognition of the Onodi cell is necessary to avoid injury to closely associated structures, including the internal carotid artery and the optic nerve. This article describes the central Onodi cell, a variation in which a posterior ethmoid cell lies superior to the sphenoid sinus in a midline position with at least one optic canal bulge. To our knowledge, this anatomic variation has not been previously reported in the literature. Radiographic and endoscopic imaging of this unique variation is provided.
Anatomic variation; computed tomography; endoscopic sinus surgery; endoscopic skull base surgery; ethmoid sinus; Onodi cell; optic nerve; parasellar anatomy; sphenoid sinus; transsphenoidal surgery
Epistaxis is one of the most frequent emergencies in rhinology. Patients using anticoagulative medication are at increased risk for epistaxis. We evaluated the prothrombin time and the international normalized ratio (INR) in anticoagulated epistaxis patients. Patients suffering from epistaxis were prospectively included in a database and results from prothrombin testing were analyzed in the context of anticoagulation. One hundred sixteen of 591 epistaxis cases were identified to be on oral anticoagulation. The INR was found to be above therapeutic levels in 19 (16%) of these cases. We strongly recommend prothrombin time and INR testing in all epistaxis patients taking any sort of vitamin K antagonists.
Anticoagulation; clotting; coumarin; epistaxis; INR; international normalized ratio; nose bleeding; prothrombin time; quick; screening; warfarin
Chronic rhinosinusitis (CRS) is an inflammation of the nose and paranasal sinuses lasting for ≥12 weeks. Endoscopic sinus surgery (ESS) is considered during difficult to treat CRS. The minimally invasive technique focuses on the transition areas rather than on the ostia. The aim of this study was to evaluate symptoms, the number of acute sinusitis episodes, and satisfaction after ESS with either preservation or enlargement of the maxillary sinus ostium. Thirty patients with moderate nonpolypous CRS were enrolled. Uncinectomy only and additional middle meatal antrostomy were randomized for each side of each patient and performed single blindly. The symptoms questionnaires were filled at four time intervals. Significant symptom reduction was achieved independently of operation technique. The number of acute sinusitis episodes indicating the exacerbation rate decreased significantly at 9 and, on average, 68 months postoperatively. However, the exacerbation rate began to increase after 9 months postoperatively. Three revisions were performed on the side with uncinectomy only and one on the side with additional antrostomy. Most patients reported good satisfaction with both procedures. There was a trend for patients with asthma and/or job exposure to report insignificantly more frequently no satisfaction with surgery, especially with the uncinectomy-only procedure. Both procedures seem to be efficient in providing symptom relief and satisfaction. More studies are needed to evaluate if patients with risk factors benefit more from an ostium-enlarging procedure.
Antrostomy; chronic sinusitis; endoscopic sinus surgery; ethmoidectomy; maxillary sinus; minimally invasive technique; mucosa; outcomes; quality of life; symptoms
Idiopathic sclerosing orbital inflammation is a rare finding that is poorly delineated, immune mediated, and causes severe symptoms and disability. It has been described affecting the orbit in addition to other sites within the head and neck, but has rarely been described presenting as sinusitis. A case report and literature review were performed. A 14-year-old girl with right-sided face and eye pain and pressure for >1 month presented 3 days after endoscopic sinus surgery for presumed acute sinusitis. She subsequently developed ipsilateral vision loss and hypesthesia of the infraorbital nerve. MRI revealed a mildly enhancing soft tissue intensity lesion extending from the right maxillary sinus into the pterygopalatine fossa and orbital apex through the inferior orbital fissure. Biopsy specimens of the lesion were consistent with a sclerosing inflammatory lesion. High-dose steroids led to rapid improvement in vision and pain; however, the patient was unable to tolerate steroid weaning because of recurrence of eye pain and headache. Repeat imaging showed progression of the lesion. Rheumatology was consulted and the patient's steroid therapy was altered and her medications were expanded to include azathioprine. The patient's symptoms improved and subsequent imaging showed a reduction in the size and extent of the lesion. Idiopathic sclerosing inflammation is characterized by primary, chronic, and immunologically mediated fibrosis. Patients typically have a poor response to corticosteroid treatment or radiotherapy. Immunosuppressive therapy in addition to corticosteroids is the recommended treatment.
Azathioprine; extraorbital; idiopathic; inflammation; orbital; sclerosing; sinusitis
Recently, some researchers have reported that macrophages and neutrophils were related to severe asthma. Mucus hypersecretion and persistent airway inflammation result from increased expression of mucin gene (MUC5AC). Eosinophilic chronic rhinosinusitis (ECRS) is considered as intractable rhinosinusitis. From the viewpoint of “one way one disease,” we examined whether ECRS is associated with infiltrating macrophages, neutrophils, their promotive factors, and MUC5AC. We examined 21 nasal polyps with CRS. Each specimen was fixed in 10% phosphate-buffered formalin, embedded in paraffin, processed routinely, and then prepared as semithin sections (3.5 μm). We immunohistochemically observed the macrophages by using CD68, neutrophils by using neutrophil elastase and the promotive factors, monocyte chemotactic protein (MCP) 1, IL-17A, and IL-8, in both ECRS and non-ECRS. The number of macrophages (CD68+ cells), IL-17A, and MUC5AC+ cells in ECRS were significantly greater than in non-ECRS. The mean number of MCP-1+ cells in ECRS was greater than that in non-ECRS, but not significantly. There was a significant correlation in all cases between IL-17A and macrophages or MUC5AC+ cells. Neither the numbers of neutrophils (positive cells for neutrophil elastase) nor the IL-8+ cells showed any significant differences between ECRS and non-ECRS. Our study suggested that infiltrating macrophages, IL-17A and MUC5AC, as well as eosinophils could have roles in the development of ECRS.
Eosinophilic chronic rhinosinusitis; human; IL-8; IL-17A; macrophage; MCP-1; MUC5AC; nasal polyps; neutrophil