bluuebunny/crossref_metadata_2025 huggingface dataset:
Evaluation of Telescopes and Forceps for Endoscopic Transnasal Surgery on the Maxillary Sinus
Authors: Hosemann Werner , Scotti Oliver , Bentzien Sabine
Published: August 2018

Background

Contemporary endonasal surgical treatment of chronic hyperplastic paranasal sinusitis strives for microsurgical excision of all spots of irreversibly diseased hyperplastic mucosa. However, anatomy of the maxillary sinus reveals distinct hidden areas and niches that pose problems to optical and instrumental control.

Methods

The specific range of view of common telescopes (30, 45, and 70°) inside the maxillary sinus after generous middle meatal antrostomy is analyzed in three different-sized anatomic specimens. The examinations are paralleled by investigations on the range of action of 14 surgical instruments. The results are visualized by means of a three-dimensional computed tomograph of all specimens.

Results

The different telescopes and surgical tools that are introduced via the middle meatal antrostomy reveal a specific overlap in the range of view and in the range of action, respectively. Anatomic areas that are difficult to reach e.g., are the medial and anterior parts of the sinus and the alveolar recess. An additional inferior antrostomy offers minor benefits with respect to control of the prelacrimal recess.

Conclusions

Routine surgery on the maxillary sinus in case of chronic hyperplastic pansinusitis via middle meatal antrostomy does not cover all hidden niches of the sinus. The most important area that is out of sight and control is the prelacrimal recess.
A Superantigen Hypothesis for the Pathogenesis of Chronic Hyperplastic Sinusitis with Massive Nasal Polyposis
Authors: Bernstein Joel M. , Ballow Mark , Schlievert Patrick M. , Rich Gary , Allen Cheryl , Dryja Diane
Published: August 2018

Background

The pathogenesis of chronic hyperplastic sinusitis with massive nasal polyposis is still an enigma; however, the molecular biology of this disease is beginning to become unraveled and the proinflammatory cytokines and the message and the product of these cytokines have all been identified in nasal polyps. However, the initial trigger that causes inflammation of the lateral wall of the nose to up-regulate lymphocytes and eosinophils is still unknown.

Methods

Thirteen patients with massive polyposis were studied. The mucus of the nasal cavities surrounding the nasal polyps was studied for both bacterial and fungal species. The lymphocytes of the nasal polyps were extracted and evaluated for the T-cell receptor, particularly, the variable β region of this receptor. Enterotoxins (superantigens) of the bacteria were studied. Finally, the histopathology of nasal polyps was studied.

Results

Fifty-five percent of the patients had toxin-producing Staphylococcus aureus in the nasal mucus adjacent to the polyps. Three different enterotoxins were isolated, including Staphylococcus enterotoxin A, Staphylococcus enterotoxin B, and toxic shock syndrome toxin 1. The variable B specificity for these superantigens was identified also in the polyp lymphocyte T-cell receptor.

Conclusion

A superantigen hypothesis for massive polyposis is suggested because the most common bacterial species found in the nasal mucus is Staphylococcus aureus. These bacteria produce enterotoxins in all of the cases studied and the corresponding variable β region of the T-cell receptor also was up-regulated in the polyp lymphocytes in cases studied thus far. These data taken together suggest that the initial injury to the lateral wall of the nose may be the result of toxin-producing Staphylococci. Superantigens (enterotoxins) may up-regulate lymphocytes to produce cytokines that are responsible for the massive up-regulation of lymphocytes, eosinophils, and macrophages, the three most common inflammatory cells found in massive nasal polyposis.
Objective and Subjective Evaluation of Endoscopic Nasal Surgery Outcomes
Authors: Giger Roland , Landis Basile Nicolas , Zheng Chunquan , Malis Didier-David , Ricchetti Alma , Kurt Anne-Marie , Morel Denis R. , Lacroix Jean Silvain
Published: August 2018

Background

Chronic rhinosinusitis (CRS) symptoms include nasal obstruction, rhinorrhea, and facial pain associated with rhinosinusitis disability. When resistance to medical treatment is associated with endonasal anomalies, endoscopic nasal surgery (ENS) can be proposed. However, objective and subjective assessment criteria regarding the evaluation of ENS outcomes remain unclear. The aims of this study were to evaluate the correlation between the inflammation in the nasal mucosa, objective recordings of nasal airway resistance (NAR), subjective evaluation of symptom intensity, and the impact of ENS on patient-perceived rhinosinusitis disability.

Methods

Sixty-one consecutive patients (35 men and 26 women; mean age, 37.5 years) suffering from CRS were monitored at 4 months and 2 years after ENS. All middle turbinate mucosa were analyzed for the density of nonspecific inflammatory cells. All patients scored their own subjective rhinosinusitis symptoms and complaints of rhinosinusitis disability. An active anterior rhinomanometry was performed.

Results

A good correlation was observed between subjective and objective NAR (p < 0.001). We found a significant correlation between the density of inflammatory cells in the nasal mucosa, subjective nasal obstruction, and the rhinosinusitis disability score (p < 0.001). Recurrent CRS was seen only in subjects with moderate to severe inflammation of the middle turbinate mucosa sampled at the first surgical intervention. Subjective rhinosinusitis symptoms, objective NAR, and rhinosinusitis disability improved significantly after ENS.

Conclusion

The degree of inflammation seems to be a good prognostic indicator regarding CRS recurrence. Long-term outcome after ENS for CRS showed significant improvement in subjective rhinosinusitis-specific symptoms, objective NAR, and rhinosinusitis disability.
The Percutaneous Columellar Strut
Authors: Bloom David C. , Cupp Craig L.
Published: August 2018

Background

Understanding tip support mechanisms is essential for nasal surgery, especially for preservation or augmentation of tip projection.

Methods

Support of the nasal tip often is improved by the use of struts placed between the medial crura. The percutaneous columellar strut is a technique that provides additional tip support during septoplasty and closed rhinoplasty. The strut is placed via a small vertical columellar incision.

Results

The advantage of easy and simple insertion outweighs the minor potential disadvantage of a small, visible vertical columellar scar. It is useful in addressing tip ptosis when trauma, surgery, or aging has reduced the contribution of the septum to tip support.

Conclusion

A detailed description of the percutaneous columellar strut technique and results of its application are presented.
Intravenous Antibiotics for Refractory Rhinosinusitis in Nonsurgical Patients: Preliminary Findings of a Prospective Study
Authors: Anand Vijay , Levine Howard , Friedman Michael , Krespi Yosef , Panje William , Schettino Raymond , Stankiewicz James , Tichenor Wellington , Kacker Ashutosh , Horn Corinne
Published: August 2018

Background

Some patients with persistent chronic sinusitis have either had unsuccessful surgery or have simply refused surgery. In nonsurgical candidates, when oral antibiotics and traditional therapy are unsuccessful, home intravenous (i.v.) antibiotics present an effective alternative.

Methods

Forty-five patients were assessed before treatment using a semiquantitative scoring system and visual analog scales to measure major and minor symptoms of rhinosinusitis. Computed tomography (CT) scans were assessed using the Lund-MacKay staging system; nasal endoscopic findings were documented. Seven patients had nasal endoscopy and CT results. Medical diseases known to be associated with rhinosinusitis were documented. Endoscopic-guided culture and sensitivities were obtained. After successful insertion and radiological placement confirmation, home i.v. antibiotics were administered via a peripherally inserted central catheter line. Antibiotic choice was based on the culture and sensitivity reports. Treatment continued for 6 weeks; subsequent cultures were obtained at weeks 3, 6, and 9. Nasal endoscopy was performed, and rhinosinusitis symptoms were assessed at weeks 3, 6, and 9. Follow-up CT scans were obtained at week 12 in a subset of patients.

Results

Significant improvement in symptom analysis was seen in patients receiving home i.v. antibiotics when previous oral antibiotic treatment and/or surgery had failed.

Conclusion

Home i.v. antibiotics provide an excellent alternative to surgery for patients who have either had unsuccessful surgery or who have refused surgery.
Objective Assessment of Lower Airway Involvement in Chronic Rhinosinusitis
Authors: Ragab Ahmed , Clement Peter , Vincken Walter
Published: August 2018

Background

When associated with lower airway involvement, the morbidity and the cost of chronic rhinosinusitis (CRS) can increase. The aim of this prospective study was to assess the clinical and radiological characteristics of the upper airways in CRS patients scheduled for functional endoscopic sinus surgery and to correlate these findings with the functional changes of the lower airways.

Methods

Twenty-five adult patients with CRS were subjected to clinical and endoscopic assessments, computed tomography scan, and allergic assessments using validated scoring systems. Lower airways were assessed by clinical history, pulmonary function test, histamine bronchial provocation test, and chest x rays.

Results

Sixty percent of CRS patients were shown to have associated lower airway involvement, i.e., 24% had asthma and 36% had small airway disease (SAD). Nasal congestion and nasal polyps were the most common clinical findings in both of these subgroups of patients. In addition, there was a negative correlation between computed tomography scan findings of the sinuses and the obstructive parameters on pulmonary function test in SAD but not in the asthma subgroup.

Conclusion

These results showed that different kinds of lower airway involvement frequently could be associated with CRS. Some are manifest such as asthma and some are hidden such as SAD and histamine bronchial hyperresponsiveness.
Local and Systemic Administration of Corticosteroids in the Treatment of Olfactory Loss
Authors: Heilmann Stefan , Huettenbrink Karl-Bernd , Hummel Thomas
Published: August 2018

Background

The aim of this study was to evaluate the benefit of patients with olfactory dysfunction from local (group A) or systemic (group B) administration of corticosteroids.

Methods

This unblinded study was conducted at a smell and taste outpatient clinic of an institutional referral center. Patients with olfactory loss after infections of the upper respiratory tract, patients with apparent sinonasal disease, and patients suffering from “idiopathic” smell loss were included. Effects of mometasone nasal spray, administered for 1–3 months, were studied in 37 patients. In addition, effects of oral prednisolone were analyzed in 55 patients who received decreasing doses over 21 days, starting with a dose of 40 mg. Olfactory function before and after treatment was measured.

Results

Although odor identification scores tended to increase (p = 0.05), mometasone nasal spray did not significantly improve olfactory function, when looking at the entire group of patients or when analyzing the three diagnostic categories separately. In contrast, after systemic administration of corticosteroids, improvement of olfactory function was seen over all diagnostic categories (p < 0.001). Interestingly, olfactory function also improved in patients diagnosed with olfactory loss after upper respiratory tract infection (p = 0.05) and in patients initially diagnosed with “idiopathic” olfactory dysfunction (p = 0.008).

Conclusion

In many patients, local application of corticosteroids appears to have little or no positive effect on olfactory dysfunction, especially when considering long-term changes. Duration of disease, the patient's age/sex, or the presence of parosmia does not appear to predict the response to therapy with corticosteroids.
The Low Skull Base: An Invitation to Disaster
Authors: Stankiewicz James A. , Chow James M.
Published: August 2018

Background

Knowledge of anatomy including variations observed with endoscopy or computerized tomography scan is vital to the performance of safe endoscopic sinus surgery. The lower-than-normal skull base/cribriform plate is an anatomic variation, which if not noted preoperatively, can lead to entrance into the brain causing major injury.

Methods

Four case studies of chronic rhinosinusitis are reviewed in which either the whole anterior skull base or the cribriform plate is lower than usual and major complications occurred.

Results

All four cases had unilateral or bilateral entrance into the skull base/cribriform plate of the brain in the biopsy specimen, postoperative cerebrospinal fluid leak, and/or brain hemorrhage. One patient died from the injury, three patients had marked neurological sequelae. The low skull base and its meaning for the surgeon is discussed at length.

Conclusion

The preoperative anatomy as determined by endoscopy and computerized tomography scanning has to be identified. Variations or abnormalities should be noted and taken into consideration for preoperative and operative planning. Failure to note skull base or cribriform anatomy variations may lead to brain entrance, injury, and death.
Nasal Dyspnea: The Place of Rhinomanometry in its Objective Assessment
Authors: Schumacher Michael J.
Published: August 2018

Background

“Nasal dyspnea” describes the common symptom of nasal airway obstruction, which usually is assessed subjectively. Objective, quantitative methods are needed to assess the nasal airway adequately.

Methods

Rhinomanometry, in use for >30 years, was reviewed.

Results

No other symptom of rhinitis can be measured as objectively and accurately as that of nasal obstruction. Determinations by rhinomanometry are precise, usually better than 5%. Most rhinomanometers meet the published requirements of standardization by the International Rhinologic Society. An improved system for scoring symptoms of nasal dyspnea is suggested. Rhinomanometry, potentially a gold standard for the objective measurement of obstructed nasal airflow, has a proven place in the selection of patients for septal and nasal valve reconstruction.

Conclusion

Recommendations are given for extension of the standards to account for the near universal computerization of equipment. Miniaturization of equipment will increase its application to trials of drugs for rhinitis.
Nasal Pyriform Aperture Stenosis in Adults
Authors: Erdem Tamer , Ozturan Orhan , Erdem Gulnur , Akarcay Mustafa , Miman Murat Cem
Published: August 2018

Background

Congenital nasal pyriform aperture stenosis (CNPAS) leading to respiratory insufficiency in infants has been well documented. Nevertheless, the nasal pyriform aperture stenosis (NPAS) entity in adulthood has not been discussed at all. The normative data of the width of the pyriform aperture, which has not been revealed before, is necessary for evaluation of the adult subjects with nasal bony inlet stenosis. The aim of this study was to define the normative data about the pyriform aperture width measured in 80 adult subjects with paranasal sinus symptoms without nasal obstruction and, additionally, to report the surgical results of two representative cases with NPAS.

Methods

The nasal bony inlet width measurements have been achieved in axial computerized tomographic sections to establish normative data. The maximal distance between the nasal processes of the opposite maxillary bones was measured. Two adult males complaining of nasal obstruction with overt pyriform aperture stenosis were treated surgically via a sublabial approach.

Results

The mean widest dimension of the nasal pyriform aperture was 21.6 6 2.2 mm (range, 17–27 mm) in 80 adult subjects. This width was 21.9 6 2.1 mm (range 18–27 mm) in men and 21 6 2.2 mm (range, 17–26 mm) in women. Stenotic pyriform apertures in two patients were widened surgically by drilling via a sublabial approach from 12 and 10 mm to 24 and 21 mm, respectively.

Conclusion

NPAS should be included in the list of differential diagnosis for nasal obstruction. Surgical enlargement using a sublabial approach was found an effective and adequate treatment in pyriform aperture stenosis.
Inflammation and the Pathogenesis of Inverted Papilloma
Authors: Roh Hwan-Jung , Procop Gary W. , Batra Pete S. , Citardi Martin J. , Lanza Donald C.
Published: August 2018

Background

Despite existing clinical and histopathological evidence, the role of inflammation in the pathogenesis of inverted papilloma (IP) is not well understood. The goal of this study was to describe the inflammatory cell component present in sinonasal papilloma (SP), with the intention of further defining the existence of inflammation in IP and perhaps gaining insight into IP pathophysiology.

Methods

Computerized database analysis was performed to identify all patients with SP who underwent surgery at the Cleveland Clinic Foundation between 1995 and 2001. Histopathological features of all SP were reviewed and semiquantitative analysis of the inflammatory cells present was performed. IP was histopathologically graded into four categories by the extent of inflammatory infiltrate and cellular atypia. Statistical analysis of the inflammatory cell component present in the epithelial layer of exophytic papilloma and IP was performed.

Results

SP was classified into three types: cylindrical papilloma (5% [2/41]), exophytic squamous papilloma (34% [14/41]), and IP (61% [25/41]). Twenty-eight instances of IP in 25 patients were identified. Altogether, 11% were grade I (3/28), 54% were grade II (15/28), 25% were grade III (7/28), and 11% were grade IV (3/28). The inflammatory cell population was significantly greater in IP compared with other SPs and greater in grades I and II IP when compared with grade III and IV IP.

Conclusion

Inflammatory cells were identified as a significant cell population in IP, whereas it was less commonly encountered in other forms of SP. The proposed IP staging system may serve as the foundation for improved understanding of IP and, ultimately, may help to predict recurrence or apparent malignant transformation.
Management of the Lateral Frontal Sinus Lesion and the Supraorbital Cell Mucocele
Authors: Chiu Alexander G. , Vaughan Winston C.
Published: August 2018

Background

Masses that radiographically appear in the lateral aspect of the frontal sinus can be difficult to access and often are approached through external approaches. Supraorbital ethmoid cells pneumatize the orbital plate of the ethmoid bone to lie posterior and lateral to the frontal sinus. Opacification of a supraorbital cell may radiographically give the appearance of a laterally based frontal sinus lesion. Often, these represent mucoceles, in which their drainage can be achieved through endoscopic techniques and without the need for an external approach.

Methods

Retrospective review of patients treated for lateral frontal sinus lesions at a tertiary sinus center was performed. Radiology, endoscopic findings, operative reports, and patient symptoms were reviewed.

Results

Ten patients were identified with lateral frontal sinus lesions based on radiography of the paranasal sinuses and nasal endoscopy. All patients were determined to be supraorbital mucoceles. These patients underwent surgical drainage using computer-aided endoscopic techniques. Initially, endoscopic drainage of the mucocele was successful in all patients. One patient was lost to follow-up after 3 months and one patient underwent a revision endoscopic surgery with trephination 5 months after the initial drainage. The remaining eight patients remain free of disease by nasal endoscopy and postoperative computed tomography scans (median follow-up of 25 months; range, 8–38 months).

Conclusion

Knowledge of the anatomy of the ethmoid complex and presence of various cells within the frontal recess such as supraorbital cells are important in the management of the laterally based frontal sinus lesion. Often, these lesions may represent supraorbital cell mucoceles amenable to endoscopic drainage. Given the nature of mucoceles, long-term follow-up is needed before endoscopic drainage of these lesions can be validated. However, preliminary data suggest that an endoscopic approach provides for adequate drainage and helps avoid external approaches.
Learning Curves, Acquisition, and Retention of Skills Trained with the Endoscopic Sinus Surgery Simulator
Authors: Uribe S. Jose I. , Ralph Walter M. , Glaser Aylon Y. , Fried Marvin P.
Published: August 2018

Background

As an initial step in evaluating the effectiveness of training otolaryngology residents on an endoscopic sinus surgery simulator (ES3), we have assessed the ability of the ES3 to train persons inexperienced in sinus surgery (medical students) to perform certain simulated procedural tasks needed in endoscopic sinus surgery (ESS).

Methods

A total of 26 medical students were enrolled and trained on the ES3 following a preset protocol in the three levels of difficulty and complexity (novice, intermediate, and advanced modes).

Results

In the novice mode (three-dimensional abstract images are used to teach the use of endoscopic surgical equipment), medical students displayed a steep learning curve within three to five trials on the simulator and after an additional four to five trials, they reached a plateau in their learning curves to within 90% of that of experienced sinus surgeons. In the intermediate mode (ESS is performed on a simulated patient with teaching aids), medical students were able to reach a plateau in their learning curves to within 80% of that of experienced surgeons. This performance was sustained in the advanced mode (simulated sinus surgery without teaching aids). We observed that medical students, who had novice or intermediate mode training interrupted with an interval of 11–60 days, were able to resume their training without deviation from their prior learning curves.

Conclusion

Intensive, proctored training on the ES3 can train inexperienced persons to perform simulated ESS within a reasonable approximation of the performance of experienced sinus surgeons on the ES3 and the training that an inexperienced person receives on the simulator is not short term but is retained over a period of at least 2 months.
An Endoscopic Study of the Greater Palatine Nerve
Authors: Mellema Jonathan W. , Tami Thomas A.
Published: August 2018

Background

Using an endoscopic approach, lateral sphenoid air cells and terminal branches of the internal maxillary artery often can be accessed through the pterygomaxillary fossa; however, injury to the greater palatine nerve (GPN) can occur if the anatomy of this region is not understood clearly. This study was undertaken to define the pathway of the GPN and to identify landmarks useful in preventing its injury.

Methods

Six cadaveric heads were used to endoscopically dissect and examine 11 pterygomaxillary fossae. An additional latex-injected cadaveric head was sectioned coronally and dissected bilaterally. The relationships between the vascular, neurological and bony structures and foramena were noted and described.

Results

All specimens studied maintained consistent relationships. The sphenopalatine and posterior nasal arteries cross nearly perpendicular and just superficial to the GPN. The GPN traveled anteriorly and inferiorly to reach the greater palatine foramen. The lateral wall of the canal ranged from a thin bony covering to complete dehiscence and was thinnest as it crossed the inferior turbinate and approached the foramen. The foramen rotundum was located lateral and superior to the sphenopalatine foramen near the roof of the maxillary sinus.

Conclusion

When surgically approaching the pterygomaxillary fossa, injury to the GPN is avoidable by thorough knowledge of anatomy and awareness of the described landmarks.
A Preliminary Report on the Effects of Paclitaxel-Impregnated Stents on Sheep Nasal Mucosa
Authors: Herrmann Brian W. , Citardi Martin J. , Vogler George , Gardner Laura , Smith Greg , Javer Amin R. , Burt Helen M. , Jackson John , Kuhn Frederick A.
Published: August 2018

Introduction

Traditional frontal sinus stents serve only as mechanical devices. It has been proposed that stents also may serve as drug-delivery systems for the topical application of drugs that minimize postoperative scarring. Paclitaxel (Taxol), which has recognized antiscarring effects, may be incorporated via a polymeric formulation into standard rubber stents. The impact of topically applied paclitaxel on the morphology of the nasal mucosa is unknown.

Methods

An adult sheep model was used for this study. A modified rubber T-tube stent (incorporating paclitaxel at varying dosages) was secured to each side of the septum in four animals (eight sides). An unmodified T-tube was placed on each side of one animal, a T-tube with the drug carrier (but no paclitaxel) was placed on each side of the second animal, and T-tubes with varying paclitaxel were placed on each side of the final two animals. After 4 weeks, animals were killed and the nasal mucosa was harvested. The nasal mucosa was sectioned and stained with hematoxylin and eosin. A pathologist then assessed the nasal mucosa for vascular congestion, glandular atrophy, chronic inflammation, mucosal metaplasia, and mucosal ulceration.

Results

No consistent histopathological differences were noted in the specimens. All specimens showed varying degrees of vascular congestion, glandular atrophy, chronic inflammation, and mucosal metaplasia; the paclitaxel-impregnated stents were not consistently associated with more severe mucosal injury. Finally, mucosal ulceration was noted to be very rare in all specimens.

Conclusion

This preliminary report describes the impact of paclitaxel-impregnated stents on sheep nasal mucosa, which tolerated these stents very well. Because paclitaxel minimizes scarring reactions at very low concentrations, paclitaxel-impregnated stents may prove useful in clinical situations in which frontal sinus stenting is deemed necessary. Additional investigations with animal models, as well as clinical trials, may be warranted.
Long-Term Quality of Life Measures after Functional Endoscopic Sinus Surgery
Authors: Khalid Ayesha N. , Quraishi Sadeq A. , Kennedy David W.
Published: August 2018

Background

Chronic rhinosinusitis (CRS) is a common disease that has a significant impact on quality of life (QOL). The aim of this study was to evaluate the longer-term effects of combined medical and surgical therapy for CRS on overall health status and QOL.

Methods

We used a prospective study that utilized the Short-Form 36 Survey at baseline presentation and at a mean time of 3 years post-functional endoscopic sinus surgery to assess the general health status of patients who presented for their initial visit from 1996 to 1998. Of the 200 randomly selected patients, 150 respondents completed follow-up surveys (a 75% response rate).

Results

Eighty-nine (59.3%) women and 61 (40.7%) men were included in the study. Baseline QOL scores indicated significant differences between patients with CRS and published norms in 6/8 subscale parameters (role physical, bodily pain, general health, social function, vitality, and mental health). Significant improvement in all six categories was maintained at the end of the study period (p < 0.05) with QOL scores within limits of published norms for the general population.

Conclusion

Our data indicate that functional endoscopic sinus surgery, combined with appropriate postoperative care, is effective at maintaining a significant improvement in the overall general health status of patients for at least 3 years after surgical intervention and that the overall scores return to a range of normative values for the general population.
Anosmia after Intranasal Zinc Gluconate Use
Authors: Jafek Bruce W. , Linschoten Miriam R. , Murrow Bruce W.
Published: August 2018

Background

Zinc is an essential mineral. Beneficial zinc absorption takes place via enteral, parenteral, or cutaneous routes. However, direct application to the olfactory epithelium has been reported to cause loss of smell. Recently, intranasal zinc gluconate has been recommended as a treatment for the common cold. Severe posttreatment hyposmia and anosmia have been observed.

Methods

The case report of a typical patient is presented and analyzed in detail, followed by a series of patients with severe hyposmia or anosmia after the use of intranasal zinc gluconate.

Results

Although interindividual variation in drug response and drug effect is apparent, the severe hyposmia or anosmia appears to be long lasting or permanent in some cases. The mechanism of olfactory loss is thought to be the direct action of the divalent zinc ion on the olfactory receptor cell.

Conclusions

Zinc ions are toxic to olfactory epithelium. Reports of severe hyposmia with parosmia or anosmia have occurred after intranasal use of zinc gluconate.
Quantitative Computer-Aided Computed Tomography Analysis of Sphenoid Sinus Anatomical Relationships
Authors: Citardi Martin J. , Gallivan Ryan P. , Batra Pete S. , Maurer Calvin R. , Rohlfing Torsten , Roh Hwan-Jung , Lanza Donald C.
Published: August 2018

Background

This study describes a novel computer-generated anatomic symmetry plane as a framework for the quantitative description of sphenoid sinus anatomy. The aim of this study was to (1) determine relationships and distances between a midline sphenoid reference point (called the central sphenoid point [CSP]) and lateral sphenoid wall structures and (2) assess the incidence of anterior clinoid process (ACP) pneumatization and pterygoid recess (PR) pneumatization.

Methods

Axial computed tomography (CT) scans (1-mm slice thickness) were obtained on a VolumeZoom CT scanner (Siemens Medical, Erlangen, Germany). Mathematically derived anatomic symmetry planes were created using custom postprocessing software. A standardized review of each CT scan using surgical planning software (CBYON Suite version 2.6; CBYON, Mountain View, CA) was performed. The CSP was defined as a reference point in the midline sagittal plane at the intersection of the vertical sellar face and the horizontal sellar floor.

Results

A total of 128 sides in 64 cadaveric specimens were available for review. The incidences of ACP pneumatization and PR pneumatization were 23.4 and 37.5%. The mean distances from the CSP to the left optic canal midpoint, the left ACP entrance point, and the left PR lateral wall were 17.2, 15.6, and 27.6 mm, respectively. The corresponding distances from the CSP on the right side were 17.3, 15.8, and 28.0 mm, respectively. Measurements from the maxillary spine to the optic canal midpoint, ACP entrance point, and PR lateral wall on each side were performed also.

Conclusion

This approach provides both quantitative and qualitative understanding of sphenoid osteology and may be coupled with intraoperative surgical navigation to reduce the risks of sphenoid surgery. Both PR and ACP pneumatization are surprisingly common. Because the CSP-derived relationships may be referenced during endoscopic surgical navigation, they may provide greater clinical utility than traditional alternatives. This paradigm may facilitate a greater understanding of sphenoid anatomy and enhance surgical safety and precision.
Congenital Nasal Piriform Aperture Stenosis or Bony Inlet Stenosis: A Report of Three Cases
Authors: De Mot Peter , Hermans Robert , Jorissen Mark , Poorten Vander Vincent
Published: August 2018

Background

Congenital nasal piriform aperture stenosis is an uncommon disorder causing nasal obstruction in neonates. Findings on computed tomography (CT) greatly facilitate the diagnosis.

Methods

Three cases of congenital nasal piriform aperture stenosis are reported, with an emphasis on CT findings.

Conclusions

At birth, a diameter of the piriform aperture at the level of the inferior nasal meatus of ≥5 mm on CT may indicate a good chance of success using conservative treatment.
Possible Involvement of Nitric Oxide and Peroxynitrite in Nasal Polyposis
Authors: Kang Bor-Hwang , Huang Nan-Chieh , Wang Hsing-Won
Published: August 2018

Background

Nitric oxide (NO) is implicated in inflammation. Its role in the pathogenesis of nasal polyposis is not clear.

Methods

The expression of inducible NO synthase (iNOS), and the production of peroxynitrite represented by the formation of 3-nitrotyrosine (3-NT) were examined by immunohisto-chemistry in nasal polyps. The contents of superoxide dismutases (SODs) in nasal polyps and nasal mucosa were assessed by Western blot analyses.

Results

iNOS expression and 3-NT accumulation were noted in mucosal epithelium, vascular endothelium, and interstitial cells of nasal polyps. In comparison with our previous study on the nasal mucosa from patients with rhinitis, the stromal cells of the nasal polyp had higher labeling intensity for both iNOS and 3-NT. The polyp showed similar levels of CuZnSOD and MnSOD as those of nasal mucosa.

Conclusions

The iNOS/NO system may be important in the pathophysiology of nasal polyposis. The increased peroxynitrite may result from increased iNOS expression but is not related to decreased SODs.
Pulmonary Arterial Pressure in Children with Allergic Rhinitis
Authors: Reisli Ismail , Oran Bulent , Baspınar Osman , Baysal Tamer , Karaaslan Sevim
Published: August 2018

Background

Chronic upper airway obstruction may lead to increased pulmonary arterial pressure in childhood. Allergic rhinitis is one of the frequent causes of upper airway obstruction by nasal blockage. The aims of the study were to evaluate the pulmonary arterial pressures in children with allergic rhinitis and the effect of topical corticosteroid therapy.

Methods

Forty-nine children composed of 27 subjects with seasonal and 22 subjects with perennial allergic rhinitis were enrolled in this study. The pulmonary arterial pressures were measured by using Doppler echocardiography.

Results

The pretreatment pulmonary arterial systolic, mean, and diastolic pressures of study group were significantly higher than in healthy controls (p < 0.05). The pulmonary arterial systolic and mean pressures of the patient group significantly decreased at the end of study (p < 0.05), whereas the decrease of the diastolic pressure was not statistically significant (p > 0.05) after the treatment of a topical corticosteroid, mometasone furoate (100 μg per day), for 8 weeks.

Conclusion

Our results showed that children with allergic rhinitis have higher pulmonary arterial pressure levels compared with healthy controls and that increased pulmonary arterial pressure levels due to allergic rhinitis are reversible by using nasal topical corticosteroids. Further studies are needed to determine the clinical aspect of increased pulmonary arterial pressure.
Endoscopic Sinus Surgery in Patients with Chronic Hepatic Failure Awaiting Liver Transplant
Authors: Delgaudio John M. , Martinez Enrique J.
Published: August 2018

Background

Because of the need for posttransplant immunosuppression, patients with chronic liver failure requiring transplantation must be free of infection to maintain an active status on the transplant list. These patients present significant surgical risks due to coagulopathy. Here, we present our experience with endoscopic sinus surgery for medically refractory sinusitis in this patient population.

Methods

We created a prospective case series of seven patients undergoing 10 surgeries.

Results

All patients were given preoperative blood product infusions. Operative blood loss ranged from 150 to 1500 cc with an average of 495 cc. Two cases had to be stopped before completion because of bleeding obscuring visualization. The two cases with the greatest blood loss were in patients with the most severe liver disease (highest mathematical model for end-stage liver disease scores), lowest albumin, and most extensive sinus disease. All patients were returned to active status on the liver transplant list and four patients have undergone liver transplantation.

Conclusion

Patients with chronic hepatic disease awaiting liver transplant can be treated successfully with endoscopic sinus surgery, but significant perioperative bleeding may not be avoidable. Preoperative use of fresh frozen plasma, platelets, and sometimes albumin are necessary, and postoperative blood products may be required with more significant sinus and liver disease. NovoSeven (recombinant factor VIIa) was used on two occasions in one patient, with maximal correction of the patient's coagulopathy. Patients should be counseled on the possible need for additional procedures to adequately clear disease.
The Learning Curve in Minimally Invasive Pituitary Surgery
Authors: Sonnenburg Robert E. , White David , Ewend Matthew G. , Senior Brent
Published: August 2018

Background

Minimally invasive pituitary surgery (MIPS) is performed via an endoscopic transnasal transsphenoidal approach. This provides excellent illumination, visualization, and magnification of the operative field, in addition to avoiding complications associated with other approaches. In this study we examined the first 45 cases of MIPS to determine if a learning curve exists for this technique.

Methods

A retrospective chart review was performed of the first 45 cases of MIPS at a major academic medical center. Cases were divided into three groups of 15 patients each. Group characteristics including age, sex, and revision surgery were compared. Complication rates investigated included death, intracerebral hemorrhage, intraoperative cerebrospinal fluid leak, postoperative cerebrospinal fluid leak, use of lumbar drain, meningitis, postoperative epistaxis, ophthalmoplegia, visual impairment, and diabetes insipidus. Other factors examined included intraoperative blood loss, length of stay, and tumor histology. One way analysis of variance statistical analysis was used to determine the significance of differences between groups.

Results

Groups were comparable in respect to characteristics studied. Statistically significant (p < 0.05) differences in complication rates and other factors between groups were not shown. Complication rates are low.

Conclusion

This study does not establish a learning curve for our first 45 cases of MIPS. This finding supports the concept that an otolaryngology/neurosurgery team skilled in endoscopic techniques and pituitary surgery can safely transition from open approaches to an endoscopic approach in pituitary surgery.
Chronic Sinusitis with Nasal Polyps: Staphylococcal Exotoxin Immunoglobulin E and Cellular Inflammation
Authors: Conley David B. , Tripathi Anju , Ditto Anne M. , Reid Kathryn , Grammer Leslie C. , Kern Robert C.
Published: August 2018

Background

The etiology of chronic sinusitis with nasal polyposis (CS/NP) remains enigmatic. Frequently, Staphylococcus aureus is present in the nose of CS/NP patients, although the significance is unclear. Recent reports have suggested the hypothesis that these bacteria may secrete exotoxins triggering the inflammatory mucosal changes seen in CS/NP. This mechanism of immunopathology has been established in other diseases associated with Staphylococcus colonization and exotoxin secretion such as atopic dermatitis. In atopic dermatitis, the exotoxins incite a local superantigen response in which clonal T-cell activation and massive cytokine release occur in the affected skin. Second, these exotoxins can act as traditional allergens, stimulating a typical immunoglobulin E (IgE) response in the serum, which has been correlated with disease severity. This study is designed to begin the assessment of the hypothesis that a similar mechanism takes place in CS/NP.

Methods

Serum was drawn from patients with CS/NP undergoing endoscopic sinus surgery as well as 13 atopic and nonatopic control subjects without sinusitis. IgE levels to S. aureus exotoxins A (SEA), SE exotoxins B (SEB), and toxic shock syndrome toxin 1 were measured using enzyme-linked immunosorbent assay. Tissue eosinophilia and the presence of lymphocytes on hemotoxylin and eosin-stained sections of polyps were scored by a blinded pathologist and correlated to presence of toxin IgE in the serum.

Results

Staphylococcal exotoxin (SE)-specific IgE was found in the serum of 5/10 (50%) of the patients with CS/NP. In contrast, 0/13 control patients had IgE to the exotoxins (p = 0.031). Polyp eosinophil, lymphocyte, and mononuclear cell counts were compared in IgE exotoxin-positive and -negative subjects. A trend toward increased eosinophil counts in patients with SE IgE (SE IgE+) was present, but not statistically significant.

Conclusion

These results indicate that a high percentage of CS/NP patients show a systemic IgE response to S. aureus exotoxins in comparison with controls without CS/NP. Although these results are consistent with the actions of Staphylococcus toxins in other diseases, additional work is necessary to establish a local superantigen response in the nasal mucosa of CS/NP patients. (American Journal of Rhinology 18, 273–278, 2004)
How Subjective is Nasal Endoscopy? A Study of Interrater Agreement using the Lund and Mackay Scoring System
Authors: Annamalai Sivakumar , Davis Jeremy , Kubba Haytham
Published: August 2018

Background

Scoring systems exist to standardize the recording of nasal endoscopy findings. The extent to which two surgeons will agree on the findings of nasal endoscopy in adults currently is unknown, although a study in children showed high rates of agreement between two observers. We studied the interobserver agreement of adult nasal endoscopy scored with the system proposed by Lund and Mackay. Method: A consecutive series of otolaryngology patients attending with a variety of nasal complaints were recruited. All were examined with a 0o 4-mm endoscope by two surgeons on the same clinic visit. Each independently recorded their findings using the Lund and Mackay scoring system. Neither surgeon was aware of the other's findings.

Results

Thirty patients were studied (16 women and 14 men). Because the endoscopic findings were recorded separately for each side of the nose, each surgeon made 60 observations. Interrater agreement was calculated as Cohen's κ, and suggested moderate agreement for edema (κ = 0.45), good agreement for crusting (κ = 0.62), and very good agreement for polyp (κ = 0.93) and discharge (κ = 0.84).

Conclusions

Two independent observers agree on the findings of nasal endoscopy in a high proportion of cases. Nasal endoscopy is a reliable tool, especially when a scoring system such as that of Lund and Mackay is used. (American Journal of Rhinology 18, 301–303, 2004)
Magnetic Resonance Imaging Findings of Inverted Papilloma: Differential Diagnosis with Malignant Sinonasal Tumors
Authors: Maroldi Roberto , Farina Davide , Palvarini Laura , Lombardi Davide , Tomenzoli Davide , Nicolai Piero
Published: August 2018

Background

Computed tomography and magnetic resonance imaging (MRI) are the techniques of choice for pretreatment staging in neoplasms of the sinonasal tract. In inverted papilloma (IP), the information provided by computed tomography regarding characterization of the lesion is rather nonspecific. The present retrospective study was performed in the attempt to identify distinguishing features of IP on MRI.

Methods

MRI examinations of 23 patients affected by IP (16 primary and 7 recurrent) and 23 patients affected by malignant tumors (MT; 12 adenocarcinomas, 9 squamous cell carcinomas, and 2 neuroendocrine carcinomas) of the sinonasal tract were evaluated. IP arose from the lateral nasal wall in 17 cases, the maxillary sinus in 5 cases, and the nasal septum in 1 case. The signal intensity of IP and MT was compared with muscles on spin-echo (SE) T2 and SE T1 images; contrast enhancement was compared with nasal septum mucosa. Possible specific MRI patterns in the two groups of patients were investigated. Bone involvement was graduated as remodeling or erosion (focal, ≤15 mm; intermediate, >15 mm and ≤30 mm; extended, >30 mm). The size of the lesions was assessed by measuring the greatest diameter on MRI. Parametric statistics in the form of Student's t-test or chi-squared test was used for data comparison.

Results

IP showed a columnar pattern in all 23 cases by enhanced SE T1 images and in 16 of 23 lesions (>20 mm in diameter) by SE T2. This pattern was observed in only 1 of the 23 MTs; pathological examination of that specimen showed multiple foci of IP associated with squamous cell carcinoma. Bone remodeling was observed in 19 of 23 IPs, which in four patients was associated with focal (two cases) or intermediate (two cases) erosion. In MT, remodeling was present, which was always combined with focal (2 cases) or extended (21 cases) erosion. A strong correlation was found between the pattern of bone changes and histology (p = 0.00001). Bone alterations did not correlate with the size of the IP. The mean size of the IPs was significantly less than that of MT (33.9 ± 15.7 mm versus 59 ± 16 mm; p = 0.0003).

Conclusion

A columnar pattern is a reliable MRI indicator of IP and reflects its histological architecture (positive predictive value of 95.8%). The combination of this finding with the absence of extended bone erosion allows for the confident discrimination of IPs from MTs. (American Journal of Rhinology 18, 305–310, 2004)
Evaluation of Protective and Therapeutic Effects of Dexpanthenol on Nasal Decongestants and Preservatives: Results of Cytotoxic Studies in Vitro
Authors: KlOucker Norbert , Rudolph Peter , Verse Thomas
Published: August 2018

Background

More than 600 million units of nasal decongestants are sold worldwide annually. The cytotoxic and ciliary toxic potential of decongestants, as well as the preservatives of these products, in particular benzalkonium chloride (BKC), is well established. Recently, a beneficial effect of dexpanthenol on the tolerability of the ά-sympathomimetic xylometazoline and BKC has been described; however, it was unclear if this effect, resulting in significantly higher cell counts in a cytotoxicity study and an increase in ciliary beat frequency in a ciliary toxicity study was of protective or therapeutic nature. The objective of this study was (a) to evaluate whether dexpanthenol would be a useful additive to nasal decongestants to counter the cytotoxic and ciliary toxic effects of the active ingredient and the preservative and (b) to find out whether this beneficial effect is of protective or therapeutic nature.

Methods

Systematic cytotoxic in vitro tests were performed. After exposure to xylometazoline (0.1%), the effect of dexpanthenol (5%) and BKC (0.01%) was determined by placebo-controlled assessment of cell growth in a human amniotic cell line.

Results

Dexpanthenol significantly reduces the toxic effects of xylometazoline regarding cell growth (p < 0.001) when applied in advance. When BKC is eliminated from the nasal sprays, a further significant increase of cell growth was found (p < 0.001). When dexpanthenol is therapeutically applied after xylometazoline, effects on cell growth are only one-half of those of the protective approach.

Conclusion

The additive application of dexpanthenol (5%) given before nasal decongestants or preserved nasal sprays is able to improve the tolerability of these substances and to counteract the toxic effects. (American Journal of Rhinology 18, 315–320, 2004)