bluuebunny/crossref_metadata_2025 huggingface dataset:
Arytenoid Prolapse following Laryngotracheoplasty
Authors: Hart Catherine K. , Richter Gresham T. , Cotton Robin T , Rutter Michael J
Published: August 2008

Objective

Dynamic arytenoid prolapse (AP) is a potential and often late source of upper airway obstruction in children following laryngotrachoplasty (LTP). Reasons for this occurrence remain unclear. We examined the incidence and clinical features of AP in patients following LTP to explore the etiology and optimal surgical approach to this problem.

Methods

Retrospective database and chart review of children diagnosed with AP after LTP at a pediatric tertiary care institution from 1981–2007.

Results

120 patients with no history of AP were diagnosed with AP following LTP (incidence 7.3% = 120/1634). 63 patients had unilateral prolapse, while 57 had bilateral AP. Average time from LTP to presentation was 44 months. Common symptoms were dyspnea on exertion, tracheostomy‐dependence, and sleep‐disordered breathing. Posterior cricoid interventions and revision LTP were most frequently associated with postoperative AP. 64% (n=77) of patients required surgical intervention. Endoscopic arytenoid reduction (AR) was performed in 54 patients, while 13 underwent AR during revision LTP. 2 patients underwent AR with cordotomy. Tracheostomy was performed with AR in another 2 patients. 28 patients required a second procedure for persistent prolapse. 36%(n=42) of patients did not require surgery. Airway complaints were relieved, or tracheostomy decannulation was achieved, in all patients after AR in which AP was the source of obstruction (avg. f/u=34.4mos).

Conclusions

Dynamic AP is a notable cause of airway obstruction following LTP. Subtle airway complaints and decannulation failures are common clinical features. Both endoscopic and open AR procedures are successful in relieving AP. Potential etiology for AP after LTP is discussed.
Does Adenotonsillectomy Cure Pediatric Sleep Apnea?
Authors: Friedman Michael , Soans Rohit , Bozkurt Ziya , Lin Hsin‐Ching , Joseph Ninos J
Published: August 2008

Objective

1) Perform an updated meta‐analysis to determine the cure rate of adenotonsillectomy for pediatric sleep apnea. 2) Report the findings of 5 years of experience with standardized coblation intracapsular tonsillectomy for the treatment of pediatric sleep apnea.

Methods

A thorough literature search of multiple databases was performed. Inclusion criteria for studies were: 1) Adenotonsillectomy as the primary treatment of sleep apnea (age<18). 2) Pre‐and postoperative polysomnography data was included. 20 studies fit the inclusion criteria and a metaanalysis was performed to determine the overall success. A 5–year retrospective analysis of coblation tonsillectomy performed by a single surgeon for sleep apnea was also performed.

Results

The meta‐analysis included 904 subjects with average follow‐up time of 21.6 weeks. The effect measure was the percentage of pediatric patients with OSAHS who were successfully treated (k= 20 studies) with T/A based on pre‐and postoperative PSG data. Random‐effects model estimated the treatment success of adenotonsillectomy was 61.1%. When “cure” was defined as an AHI of <1, the cure rate was 53.8%. 200 adenotonsillectomy cases performed with coblation technique were reviewed. The mean preoperative was AHI 28.3 and mean postoperative AHI was 3.8. Surgical cure, as defined as a postoperative AHI <1, was achieved in 51.7% of patients.

Conclusions

1) Contrary to popular belief, meta‐analysis of current literature and a review of 200 cases demonstrates that pediatric sleep apnea is often not cured by adenotonsillectomy. 2) Although complete resolution is not achieved in most cases, adenotonsillectomy still offers significant improvements in AHI.
Ear Malformations: Surgical Considerations
Authors: Granstrom Gosta , Salen Joachim , Schubertsson Katharina
Published: August 2008

Objective

Therapy of ear malformations has changed considerably the last two decades when new surgical techniques are available. This study aimed to evaluate different approaches to improve hearing and esthetics in ear malformations.

Methods

All patients who underwent rehabilitation for ear malformations between 1960 and 2007 at a University Hospital were investigated. Patients underwent clinical, audiological and x‐ray examinations. Attempts to improve hearing were undertaken by ear canal and middle ear reconstruction, and/or bone anchored hearing aid (BAHA). Attempts to improve esthetics of the external ear were undertaken by autogenous reconstruction (AR) and bone anchored episthesis (BAE).

Results

There were 211 patients (117 male, 94 female) with ear malformations representing 255 ears. 103 of these were syndromic patients. The degree of ear malformation was generally severe, Meurman stage 3 (external ear) and Altman Creemers stage 2B (middle ear). AR (n=64) was successful to a higher degree in milder malformations (93% for Meurman grade 1, 18% for Meurman grade 3). BAE (n=109) was successful to a high degree independent of Meurman degree (92–100%). A mean of 17 dB closure of air‐bone gap was obtained by ear canal and middle ear reconstruction (n=111). A mean of 46 dB closure of air‐bone gap for BAHA was obtained (n=106).

Conclusions

With the high degree of success for BAE, this option is valuable for children where AR has failed. With the high degree of success for BAHA, children can be supplied with BAHA early and middle ear reconstruction postponed until adolescence.
Etiology of Pediatric Recurrent Croup
Authors: Muntz Harlan R , VanWoerkom Ryan
Published: August 2008

Objective

Often pediatric croup is viral in etiology. Children with recurrent croup (greater than 3 episodes a year) may have underlying pathology making them more prone to these episodes. This study was done to define the frequency of these pathologies.

Methods

80 consecutive children with the diagnosis of recurrent croup underwent diagnostic endoscopy at a pediatric tertiary care hospital. We carried out a retrospective chart review of these cases.

Results

Of the 80 children, 26 (33%) were found to have subglottic stenosis. The average narrowing was 32 ± 9% in these children. Of the 26 with subglottic stenosis, 19 (73%) also manifested laryngopharyngeal reflux. Of the 15 (19%) patients previously intubated as neonates or infants, 8 (53%) also had subglottic stenosis. 45 (56%) were felt to have laryngopharyngeal reflux by either laryngotracheal findings or other testing. 26 (58%) of these had concomitant subglottic stenosis. Allergies or asthma were found in 31 (39%) of the patients. Another 16 (20%) were found to have tracheomalacia and an additional 7 (9%) were noted to have innominate artery compression. Many had more than one risk factor.

Conclusions

The most common factors associated with recurrent croup are laryngopharyngeal reflux and subglottic stenosis. This study will assist the clinician in discussion of possible etiologies with families and insurers. Defining underlying pathology can then assist in the defining treatment options.
Hoarseness in Children with Cleft Palate
Authors: Hamming Katherine K , Finkelstein Marsha , Sidman James D
Published: August 2008

Objective

1) To determine the rate of hoarseness in children with cleft palate (CP). 2) To understand the relationship between velopharyngeal insufficiency (VPI) and hoarseness in children with CP.

Methods

Retrospective chart review of 98 patients treated for CP by a tertiary care Children's Hospital Cleft Team and born between 1990 and 2001.

Results

Of the 98 patients, 59 were male and 39 female. All types of CP were represented. 89% received speech therapy. 41.6% had VPI. The overall rate of hoarseness was 22.4% and of dysphonia was 55.9%. The presence of VPI did not correlate with the presence of hoarseness or dysphonia. However, while VPI decreased when comparing ages 3–4 (58.1%) with ages 6–7 (32.1%) (p <0.001), the hoarseness rates did not change as children got older. Additionally, there was a trend toward higher hoarseness and dysphonia rates in children with Pierre Robin Syndrome (PRS).

Conclusions

Both VPI and hoarseness are common findings in patients with CP. VPI improves as children get older in the setting of a tertiary care cleft team and a high rate of speech therapy. However, hoarseness and dysphonia do not appear to improve. These findings suggest that the theory that VPI causes hoarseness due to compensatory speech mechanisms may be incorrect. Even when resonance problems have improved, CP patients should continue to be evaluated by speech therapists for voice disturbances, as well as evaluated by otolaryngologists for treatable causes of hoarseness. Further, patients with PRS may be at additional risk for voice disturbances and should be treated accordingly.
Intranasal Steroids for Adenoidal Nasal Obstruction
Authors: Chadha Neil K , Zhang Linjie , Mendoza‐Sassi Raul , Cesar Juraci
Published: August 2008

Objective

1) To systematically review the evidence for intranasal steroids in the treatment of nasal obstruction caused by adenoidal hypertrophy, in children. 2) To determine the risk of adverse events of treatment.

Methods

We performed a systematic review and metaanalysis following a specified protocol. Databases searched (May 2007) included Cochrane CENTRAL, MEDLINE, EM‐BASE, CINAHL, AMED, LILACS, KoreaMed, IndMED, SIGLE, Cambridge Scientific Abstracts, mRCT, National Research Register, ISRCTN, and ISI Web of Science.

Results

56 studies were identified, with 4 randomized controlled trials (RCTs) meeting the inclusion criteria. Trial 1: an 8‐week crossover RCT demonstrating 4‐weeks beclomethasone (336 mcg/day) showed a 45% reduction in symptom scores (p<0.01). Trial 2: a 4‐week crossover RCT demonstrating a reduction in nasal obstruction index by 50% in patients treated with beclomethasone (400 micrograms/day) for 2 weeks (p<0.0001). Trial 3: a 40‐day parallel RCT which showed that 77.7% of patients treated with mometasone (100 micrograms/day) demonstrated an improvement in nasal obstruction symptoMS Trial 4: an 8‐week parallel RCT demonstrated no significant improvement in nasal obstruction symptoms after 8‐weeks treatment with beclomethasone (200 micrograms/day). Low statistical power and low dose of beclomethasone may have contributed to this negative result.

Conclusions

Current evidence suggests that intranasal corticosteroids may significantly improve nasal obstruction symptoms in children with adenoidal hypertrophy, and this improvement was associated with a reduction of adenoid size. Given the safety and tolerability of intranasal corticosteroids, it seems reasonable to recommend the use of these drugs as an effective treatment for children with adenoidal hypertrophy when adenoidectomy is not urgently required.
Lingual Tonsillectomy for Persistent Pediatric Sleep Apnea
Authors: Lin Aaron C , Koltai Peter J
Published: August 2008

Objective

1) To describe our experience with a technique of lingual tonsillectomy using coblation with endoscopic visualization. 2) To document its utility for treating children with persistent sleep apnea after adenotonsillectomy who on sleep endoscopy have enlarged lingual tonsils and tongue base obstruction.

Methods

Retrospective cohort study in a tertiary pediatric medical center. Between 2005 and 2007, 20 patients (ages 3 ‐18), who had a previous adenotonsillectomy (T&A) for obstructive sleep apnea (OSA), were diagnosed with persistent OSA by polysomnography (PSG). These children had both in‐office unsedated fiberoptic laryngoscopy and dynamic anesthesia‐assisted sleep fiberoptic laryngoscopy, both of which demonstrated lingual tonsillar hypertrophy contributing to tongue base obstruction of the hypopharynx. With a visually confirmed site of lesion, these children underwent endoscopic lingual tonsillectomy for treatment. Pre‐ and post‐operative PSG data were paired and analyzed statistically.

Results

Statistically significant reductions in respiratory distress index (RDI) were observed when pre‐ and post‐operative data were compared (mean 14.9 vs. 7.8, median 12.6 vs. 3.3). There were similar reductions in the number of apneas and hypopneas. The mean and median low O2 saturations did not change significantly.

Conclusions

Endoscopic lingual tonsillectomy is an effective technique for the treatment of lingual tonsillar hypertrophy causing persistent obstructive sleep apnea after T&A. Anesthesia‐assisted sleep endoscopy is key to diagnosing the obstructive contribution of the enlarged lingual tonsils. The combination of endoscopic access with the near bloodless technique for ablation of the lingual tonsils provides a consistently reproducible method of treating children with this uncommon problem.
Microdebrider‐Assisted Supraglottoplasty for Laryngomalacia
Authors: Groblewski Jan Casimir , Shah Rahul K , Zalzal George H
Published: August 2008

Objective

To describe our series in the surgical treatment of laryngomalacia using a microdebrider.

Methods

A retrospective review of patients undergoing supraglottoplasty for laryngomalacia at a tertiary children's hospital between October 2004 and February 2008 was performed. Patients with complex co‐morbidities and those undergoing alternative methods for supraglottoplasty were excluded. Patient charts and operative reports were reviewed to assess demographic characteristics, co‐morbidities, procedural times, hospitalizations, intra‐operative and post‐operative complications, and post‐operative outcome. Main outcome measures included complications, pain, resolution of stridor, presence of aspiration, and need for revision surgery.

Results

27 patients underwent microdebrider‐assisted supraglottoplasty. Mean age at diagnosis was 109 days; mean age at time of the procedure was 187 days. 18 Eighteen patients (67%) had gastro‐esophageal reflux at the time the laryngomalacia was diagnosed. Average operative time was 35.7 minutes (std. dev. 12.9, range 11–65 minutes). No intra‐operative complications or device problems were noted. Only 2 patients remained intubated at the conclusion of the procedure; no patient required tracheotomy or revision supraglottoplasty. One patient had post‐operative aspiration, which later resolved. One patient was readmitted for stridor one month following her procedure. There was no pain from the procedure, as all patients immediately resumed a diet. All patients had eventual resolution of stridor.

Conclusions

This is the largest series of patients that underwent microdebrider‐assisted supraglottoplasty for laryngomalacia. This procedure is safe, without pain, and effective in patients with laryngomalacia. Microdebrider‐ assisted supraglottoplasty is the method of choice for supraglottoplasty in our institution.
Molecular Resonance vs. Coblation Tonsillectomy in Children
Authors: D'Eredita Riccardo
Published: August 2008

Objective

To compare molecular resonance (MRT) with coblation (CAT) devices for pediatric tonsillectomy.

Methods

Prospective, 2‐group, randomized trial in a tertiary care pediatric institution. 89 children for whom tonsillectomy was indicated were randomly assigned to receive MRT (n=45) or CAT (n=44). Main outcome measures included intraoperative time, blood loss, postoperative pain, and weight loss. Histopathologic examination was performed on all excised tonsils. Patients, parents, and pathologist were blinded to surgical modality.

Results

Histopathologic evaluation revealed significantly reduced thermal injury with MRT than with CAT (43 microns vs. 126 respectively, p<0.001), and was statistically associated with reduced muscular, blood vessels, and nerve fibers damage. No intraoperative blood loss was observed in patients following MRT. Statistically significant reduced pain scores were related to the MRT (p<0.002). In addition, the MRT method showed a quick return to normal diet with even weight gain during the 10‐day postoperative period. One child in the CAT group experienced delayed bleeding and required read‐mission.

Conclusions

Molecular resonance for pediatric tonsillectomy resulted in significantly reduced histopathologic thermal injury, and lower pain scores as compared to coblation. Further studies are advised to support these data.
Resistant Pneumococci Causing Otitis and Sinusitis Failures
Authors: Poole Michael D
Published: August 2008

Objective

Describe cases of non‐responsive otitis media and rhinosinusitis due to highly resistant strains of Streptococcus pneumoniae.

Methods

Resistant strains of Streptococcus pneumonia were isolated from cases of non‐responsive pediatric otitis media or rhinosinusitis, from September 2005 to September 2008, from a single pediatric otolaryngology practice. Children had failed therapy with “high dose” amoxicillin‐clavulanate and/or ceftriaxone injections.

Results

54 cases of apparent failed therapy were detected. The strain(s) demonstrated in vitro high level resistance to penicillin, amoxicillin‐clavulanate, oral cepahalosporins, trimethoprim‐sulfamethoxazole, macrolides, and clindamycin; and were intermediately or fully resistant to ceftriaxone. Serotyping of representative isolated demonstrated these to be 19A pneumococcal isolates. These cases were often in unusually young infants, and often were from a single prolonged episode of acute otitis medi, including 2 cases of mastoiditis with subperiostial abscess. Most of the cases were identified by office‐based diagnostic tympanocentesis and were rarely isolated from children undergoing tympanstomy tube placement. All cases resolved after therapy with levofloxacin pediatric suspension (25 mg/ml, 20 mg'kg/day divided BID.

Conclusions

This is the largest series of otitis and sinusitis cases due to these highly resistant organisms; and these cases suggest that resistant pneumoccocci are likely causing a significant number of treatment failures in the U.S. They are not detected unless nasal or middle ear cultures are taken from treatment failures. Treatment with fluoroquinolones is effective, but raises issues concerning the role of this class of anitbiotics in children.
Safety and Efficacy of Balloon Sinus Dilation in Children
Authors: Ramadan Hassan H , McLaughlin Kevin E , Josephson Gary D , Rimell Frank L , Bent John P
Published: August 2008

Objective

The safety and feasibility of balloon catheters to dilate obstructed sinus ostia was established in adults in the CLEAR study. This minimally invasive approach to endoscopic sinus surgery is potentially advantageous for pediatric patients due to possible decrease in scarring, post‐operative pain, and need for operative debridement. This is a preliminary report on the safety and efficacy of using balloon sinuplasty instruments.

Methods

A prospective, multi‐center, non‐randomized evaluation is currently underway in pediatric patients diagnosed with chronic rhinosinusitis. To date, 35 patients (58 maxillary, 9 sphenoid, and 3 frontal sinuses) have been enrolled at 5 sites. Safety was assessed by rate of adverse events. Effectiveness was assessed through measurement of patient sinus symptoms. Patients age 12 and older completed the Sino‐Nasal Outcome Test (SNOT 20). Parent/guardians completed the SN‐5 Questionnaire for patients under age 12.

Results

No unanticipated adverse effects were noted in any patients. Patient symptoms improved on the SN‐5 from average scores of 4.7 at baseline (n=24) to 2.7 at 12 weeks post‐surgery (n=11)(p = 0.0001). Patient symptoms improved on the SNOT‐20 from 1.7 at baseline (n=10) to 0.9 at 12 weeks post‐surgery (n=5)(p = 0.33). Twelve week follow‐up data for the entire cohort is anticipated by June 2008 and the abstract will be updated accordingly.

Conclusions

Preliminary results indicate that when patients are appropriately selected, sinus ostial dilation using balloon catheters in children has an excellent safety profile and may be an effective minimally invasive treatment option to relieve sinus ostial obstruction.
Tonsillectomy for Obstructive Sleep Apnea in Obese Children
Authors: Costa Dary J , Mitchell Ron B
Published: August 2008

Objective

To determine the effectiveness of adenotonsillectomy (T&A) for treating obstructive sleep apnea (OSA) in obese children.

Methods

Meta‐analysis of studies that reported sleep parameters in obese children with OSA before and after T&A. Data was analyzed using the random effects model. Statistical significance was P less than 0.05.

Results

Data from four studies that included 110 children were analyzed. Mean sample size was 27.5 (range: 18 ‐ 33). Mean body mass index (BMI) z‐score was 2.81. The mean pre‐and postoperative apnea‐hypopnea index (AHI) was 29.0 (range 22.2 ‐ 34.3) and 9.9 (range 6.0 ‐ 12.2) respectively. The weighted mean difference between pre‐ and postoperative AHI was a significant reduction of 18.3 events per hour (95% CI 11.2–25.5). The mean pre‐ and postoperative oxygen saturation nadir was 78.9% (range 73.9 ‐81.1%) and 85.7% (83.6 ‐89.9%) respectively. The weighted mean difference was a significant increase in the oxygen saturation nadir of 6.3% (95% CI 3.9 to 8.7). Approximately 43% of children had a postoperative AHI less than 5, 21% of children had a postoperative AHI less than 2, and 11% of children had a postoperative AHI less than 1.

Conclusions

T&A improves but does not resolve OSA in the majority of obese children. Up to 89% of obese children have persistent OSA after T&A. The efficacy and role of additional therapeutic options requires more study. The high incidence of obesity in children makes this a public health priority.
Ultrasound Characterization of Middle Ear Effusion
Authors: Seth Rahul , Discolo Christopher , Krakovitz Paul R
Published: August 2008

Objective

To further 1) enhance and assess the ability to detect and characterize middle ear effusion using A‐mode ultrasonography with miniature curved array transducers, and 2) identify bacterial presence in relation to effusion viscosity.

Methods

A prospective unblinded comparison study was performed to determine ultrasound efficacy in detecting effusion characteristics. Ultrasonographic examination using an ultrasound probe was performed on 107 patients (197 ears) scheduled to undergo bilateral myringotomy with pressure equalization tube placement. With the child anesthetized, the probe was placed into the external ear canal after sterile water was inserted. Ultrasound recordings from the tympanic membrane and middle ear space were recorded and analyzed for viscosity. Middle ear aspirate was sent for bacterial culture. Myringotomy was then performed.

Results

Computer‐based algorithms analyzed the waveforms and were able to detect the presence of thick, thin, and lack of fluid with a sensitivity and specificity of greater than 90%. Thin effusions had a significantly higher infection rate (64% versus 12%, p<0.01, Fisher's exact test) when cultured from ears of children not taking oral antibiotic therapy. Similar results were obtained from cultures taken of middle ear fluid in children taking antibiotics (69% versus 12%, p<0.002).

Conclusions

The specificity and sensitivity of ultrasound middle ear fluid detection is greater than 90%, exceeding the accuracy of tympanometry and other devices. Moreover, it can accurately predict the viscosity of an effusion, which can give insight into its likelihood of infection. Further technologies to promote ease of use will be needed.
Efficacy of Pre‐Operative MRSA Screening in Otolaryngology
Authors: Richer Sara L , Wenig Barry L
Published: August 2008

Objective

To examine the efficacy of pre‐operative Staphylococcus aureus screening by nasal swab on post‐operative Methicillin‐resistant Staphylococcus aureus (MRSA) infection rates in surgical patients undergoing varied otolaryngological procedures.

Methods

Retrospective review of MRSA colonization and infection rates in surgical otolaryngology patients at a single institution. MRSA infection rates in unscreened patients undergoing procedures during a one‐year period were compared to infection rates in patients undergoing pre‐operative Staphylococcus aureus screening in an 11‐month time frame. Patients colonized with Staphylococcus aureus were treated with Mupirocin and Chlorhexidine prior to the procedure.

Results

Records of 420 patients undergoing varied otolaryngological procedures were evaluated. In the 241 patients without pre‐operative screening, 9 patients had Staphylococcus aureus‐infected wounds. There were two (0.83%) post‐operative MRSA surgical site infections. Out of 179 patients followed after screening was initiated, 24 patients (13.4%) were colonized with Staphylococcus aureus and underwent preoperative treatment. There were no MRSA infections in the post‐operative period.

Conclusions

Early results demonstrate the potential benefit of pre‐operative Staphylococcus aureus screening in reducing the MRSA infection rate. Screening and treatment of MRSA colonized patients pre‐operatively reduces infectious complications and should be considered in otolaryngology surgical practice.
Post‐tonsillectomy Bleeding as a Stochastic Process
Authors: Blakley Brian W
Published: August 2008

Objective

1) Establish an acceptable post‐tonsillectomy bleeding rate from the literature, and 2)provide a literature‐based comparator for institutional bleed rates.

Methods

A MEDLINE literature search entering the keyword “tonsillectomy” identified 4,610 papers for all available years. The abstracts were loaded into a database and searched to identify the incidence of bleeding if reported. The weighted mean, standard deviation and 95% confidence intervals were calculated for those papers. For papers that compared a new technique to a control technique, only the control group rate was used. The definitions of bleeding rate were those used by the original authors of the papers.

Results

63 papers reported post‐tonsillectomy bleeding rates. The mean (4.5%) plus 2 standard deviations (9.4%) suggests a maximum “expected” sustained bleeding rate of 13.9%. Even in this literature which should reflect optimum results, there were 3 reports of bleed rates in the 18–20% range.

Conclusions

Post‐tonsillectomy bleeding rates of about 5% are typical. Rates above 14% justify monitoring, and sustained rates over 20% occur at times. Transient increases greater than 20% may occur.
Bacterial Flora of Normal Maxillary Sinuses in Adults
Authors: Abou Hamad Walid M , Matar Nayla E. , Elias Michelle , Hokayem Nabil , Nasr Marwan W. , Sarkis Dolla Karam , Haddad Amine C
Published: August 2008

Objective

(1)To determine the bacterial flora and (2) to quantify the level of bacterial presence in healthy maxillary sinus cavities.

Methods

Subjects included 25 consecutive patients undergoing Lefort I osteotomy for orthognathic surgery under general anesthesia between January 2007 and February 2008. All patients were preoperatively evaluated by a questionnaire and a complete physical examination including sinus endoscopy. Our exclusion criteria were: presence of sinonasal symptoms, asthma, antibiotic treatment in the past 3 months, treatment with local steroids, previous sinonasal surgery, traumatic surgery, and an abnormal sinus endoscopy. Washes were obtained from maxillary sinuses before surgery through an antral puncture. The sinus was irrigated with 1cc of sterile saline followed by aspiration with a syringe attached to the trocar. Basic sterility rules were rigorously applied. Specimens were transported to the laboratory in a sealed, airfree syringe. Time between collection of materials and inoculation of the specimen did not exceed 15 minutes. Specimens were inoculated for aerobic and anaerobic organisms.

Results

After applying the selection criteria, 14 patients (28 sinuses) remained. Eight (57.1%) were males with a mean age of 22.7 years. 82.14% of the specimens were sterile. Bacterial organisms were recovered in only 4 patients with 2 different coagulase negative staphylococci in the same patient: one in each sinus with 200UFC/ml in the left sinus and 10UFC/ml in the right sinus, 1 citrobacter fundii (70 UFC/ml) and 2 polymorphic floras.

Conclusions

This descriptive study demonstrates the large predominance of sterile maxillary sinus cavities in asymptomatic adults with endoscopically normal mucosa.
Balloon Sinuplasty: Fluoroscopic vs. Illumination Guided
Authors: Friedman Michael , Soans Rohit , Soans Roshan , Joseph Ninos J
Published: August 2008

Objective

To compare two balloon sinuplasty techniques, fluoroscopic guided and illumination guided, with regards to: 1) Sensitivity and specificity of identifying the sinus; 2) Accuracy of cannulating the natural sinus ostium; 3) Ease of technique and cost.

Methods

Operative reports of 120 consecutive patients, equally representative of each technique, were analyzed to determine: 1) The success of sinus identification with the technique; 2) Evidence of endoscopic visual conformation of natural ostium dilation. The sensitivity and specificity of each technique in sinus identification was determined. The success of natural ostium cannulation was also determined. A cost analysis of each technique was performed with regards to equipment and time.

Results

A total of 330 sinuses were reviewed (fluoroscopy, n=171; illuminated guide wire, n=159). Fluoroscopy was 100% sensitive and 100% specific with regards to sinus identification; whereas the illuminated guide wire was 97.9 % sensitive and 85.7% specific. With respect to the cannulzation of the natural sinus ostium, the success rate of fluoroscopy and the illuminated guide wire was 85.9% and 87.5% respectively. These results demonstrated no significant difference between the two techniques. The elimination of fluoroscopy with the illuminated guide wire technique reduced overall cost and operative time significantly.

Conclusions

1) Balloon sinuplasty with illuminated guide wire is comparable to fluoroscopic guided with regards to sensitivity and specificity of sinus identification and successful cannulation of the natural sinus ostium. 2) Cost and operative time are reduced with the new technique.
Does Olfaction Improve After Endoscopic Sinus Surgery?
Authors: Litvack Jamie R. , Mace Jess Collin , Smith Timothy L
Published: August 2008

Objective

No large, prospective, multi‐institutional cohort studies have objectively examined the impact of surgery on olfaction with long‐term follow‐up. The aim of this study was to objectively examine the impact of endoscopic sinus surgery (ESS) on olfactory dysfunction (hyposmia) would benefit from ESS, whereas patients with severe olfactory dysfunction (anosmia) would not.

Methods

In this prospective, multi‐institutional cohort study, 111 patients presenting for ESS for treatment of CRS were examined pre‐operatively and at 6 and 12 months postoperatively. Demographic, co‐morbidity and Smell Identification Test (SIT) data were collected at each time point. Univariate and multivariate analyses were performed.

Results

The prevalence of gender‐adjusted olfactory dysfunction prior to surgery was 67.5%: 50.4% of patients were hyposmic and 17.1% were anosmic. Surprisingly, hyposmic patients did not significantly improve after surgery (baseline, 6 month, 12 month mean SIT scores: 28.8, 30.0, 29.5). In contrast, patients with anosmia significantly improved after ESS (baseline, 6 month, 12 month mean SIT scores: 9.3, 21.3, 21.7; p=0.001); furthermore, improvement was sustained at 12‐month follow‐up (p=0.001). Multivariate linear regression analysis showed that baseline olfactory category and nasal polyposis were significantly associated with improvement in postoperative olfactory function (p=0.035, p=0.002), whereas age, gender, and disease‐severity as measured by CT and endoscopy scores were not.

Conclusions

Contrary to our hypothesis, patients with severe olfactory dysfunction significantly improved after ESS and sustained improvement over time, whereas patients with mild olfactory dysfunction did not.
Effect of Sinus Surgery on Bodily Pain: A Metaanalysis
Authors: Chester Alexander C , Sindwani Raj , Smith Timothy L , Bhattacharyya Neil
Published: August 2008

Objective

To determine by systematic review and metaanalysis if (1) bodily pain as measured by the 36‐Item Short Form Health Survey (SF‐36) is consistently increased in patient populations with chronic rhinosinusitis (CRS); and (2) if SF‐36 bodily pain scores significantly and consistently improve following endoscopic sinus surgery (ESS).

Methods

Studies published in any language reporting SF‐36 results before and after ESS were retrieved by searching MEDLINE, EMBASE, Web of Science, Cochrane databases, and additional Web‐based sources (from 1980 to January 2008); by examining bibliographies of retrieved articles; and by contacting investigators in the field. Two authors independently evaluated studies for inclusion.

Results

After excluding 1 study reporting results as medians rather than as means, the remaining 10 observational ESS studies (909 patients) reported preoperative SF‐36 bodily pain scores 0.95 SDs below the general population mean (more bodily pain) in average weighted by sample size. Using a repeated‐measures design, all studies noted an improvement in SF‐36 bodily pain domain scores following surgery, with a moderate‐sized combined effect of 0.54 (95% confidence interval [CI], 040–0.69) and moderate heterogeneity (I2 = 50%). This pooled effect corresponds to a clinically and statistically significant mean improvement of 11.7 (95% CI, 7.1–16.3) units in the SF‐36 bodily pain domain.

Conclusions

Bodily pain is consistently increased in patient populations with CRS. Using within‐subject comparisons, a clinically and statistically significant improvement in bodily pain is noted after ESS, an improvement similar in size to that previously described for fatigue and other CRS symptoms.
Effects of Endoscopic Sinus Surgery and Device on Irrigation
Authors: Goddard John C , Harvey Richard J , Wise Sarah K , Schlosser Rodney J
Published: August 2008

Objective

1) Assess the effect of endoscopic sinus surgery (ESS) on the distribution of topical solutions to the para‐nasal sinuses. 2) Understand differences in topical solution distribution to the para‐nasal sinuses using various delivery devices.

Methods

Ten cadaver sinus systems were irrigated with radio‐opaque contrast prior to any surgery, after ESS, and following modified medial maxillectomy. Delivery of contrast was via pressurized spray, neti pot and squeeze bottle techniques for each surgical state. CT scans were performed before and after each irrigation using a portable CT machine. Blinded assessments were made for distribution of contrast within the sinuses. A semi‐quantitative grading scale was used to assess contrast distribution to each of 5 sinus regions (maxillary, anterior ethmoid, posterior ethmoid, sphenoid and frontal).

Results

Total sinus distribution of contrast was significantly greater post‐ESS as compared to the un‐operated state (p<0.001). Sphenoid and frontal sinus distribution was most affected by surgery. Delivery device influenced contrast distribution, with neti pot and squeeze bottle techniques providing greater distribution than pressurized spray (p<0.001). Frontal sinus penetration was greater post‐ESS (p=0.017) and neti pot delivery was the most effective frontal delivery device (p<0.001).

Conclusions

ESS greatly enhances the delivery of nasal solutions, regardless of delivery device. Limited distribution to the sinuses exists without concomitant ESS, especially for sprays. Squeeze bottle/neti pot use, post‐ESS, offers a greatly enhanced ability to deliver solutions to the para‐nasal sinuses.
Evolution with Inverted Papilloma: Analysis of 200 Cases
Authors: Patel Zara , Lawson William
Published: August 2008

Objective

Open, endoscopic and endoscopic‐assisted surgical approaches to inverted papilloma (IP) have been described. 1) Assess the evolution of management within one institution with the largest case series and longest clinical follow‐up of IP to date in the literature. 2) Compare this management with what has been recently presented in publication.

Methods

A retrospective review was performed of IP cases from 1973 to 2007, assessing gender, age, presenting symptoms, origin of lesion, staging, primary versus recurrence, radiographic findings, method of treatment, rate of recurrence, and associated malignancy. A comprehensive review of the literature was also performed.

Results

200 patients (average age, 57) underwent endoscopic or endoscopic‐assisted resection of IP. Mean follow‐up was 4.3 years (range 9 months −19 years). 80% of cases over the last decade had prior surgery before presentation. 63% were Krouse stage T3 and 25% were T4. Combined approaches were used for 57% of the most recent 40 cases, including Caldwell‐Luc, lateral rhinotomy, medial maxillectomy, trephine, or osteoplastic flap. Rate of recurrence was 13% (range 8 to 144 months), with multiple recurrences after 2 years. The rate of malignancy was 7%.

Conclusions

IP can be safely addressed endoscopically when possible, with data from this study and the current literature suggesting this is feasible in 43–66% of cases. Variables affecting the decision to use adjuvant external approaches include significant scarring and anatomic distortion from previous surgery, high Krouse stage, and associated malignancy. Long‐term follow‐up is recommended. Emerging research on HPV will likely impact future management.
Experience with 1450 Endoscopic DCR and Four Methods
Authors: De Souza Christopher E
Published: August 2008

Objective

1) Comparing 4 methods when doing a DCR. 2) Determining superiority of stenting versus fistulization.

Methods

Randomized uncontrolled study. 12 years (1994 to 2007), chronic dacryocytitis, 1195 patients studied, primary health care. 1. Resolution of Epiphora 2. Patency 3. Complete resolution of abcess Endoscopic DCR. 4 methods: simple incision, grommet insertion, stenting, and fistulization. 255 patients had their lacrimal sacs incised and drained, 300 had grommets inserted in their lacrimal in an attempt to achieve patency, 225 had lacrimal stents, and 415 had undergone fistulization.

Results

Of the 255 incisions and drainages, 65% were blocked after 2 months. Of the 300 who had grommets inserted, 68% were blocked after 2 months. Of the 225 who had lacrimal stents, all were patent but 10 (4%) had to be removed because of corneal opacities, and 1 (0.4%) had to be removed because of a foreign body granuloma at the punctum. Of the 415, 5 (1.2%) were blocked after 6 months and 1 (0.2%) patient had epiphora even though the sac was patent.

Conclusions

1) Fistulization and stenting are statistically more reliable in achieving resolution of epiphora, restoration of patency, and complete resolution of chronic dacryocystitis. 2) In our experience, we encountered corneal opacities following stenting and since the results with fistulization were comparable to stenting, we prefer to fistulize patients for chronic dacryocystitis as a safe and reliable method.
Flat Panel Cone Beam Computed Tomography of the Sinuses
Authors: Zoumalan Richard A , Yung Kathryn Shouyee , Wang Edwin , Lebowitz Richard A , Jacobs Joseph B
Published: August 2008

Objective

Flat panel cone beam CT is a relatively new technology that improves upon traditional multidetector CT scanners by generating images with greater spatial resolution at lower radiation doses. 1) Learn whether flat panel cone beam CT evaluation is an effective imaging modality for the sinuses. 2) Learn which doses of radiation provide quality evaluation of the sinuses while exposing the patient to the least amount of radiation.

Methods

In 2007, a panel consisting of neuroradiologists and otolaryngologists blindly reviewed images from flat panel sinus CTs (Xoran MiniCAT) of 11 live human subjects, each irradiated at all 3 different techniques (denoted as: low dose mAs=9.27, medium dose mAs = 18.41, high dose mAs=36.7) and rated the image quality of a pre‐designated list of sinus anatomic structures. Techniques were compared in a pairwise manner using a Wilcoxon matched‐pairs signed ranks test.

Results

Compared to the low dose technique CT scan, the high dose CT scan technique had significantly better image quality (P=.0029) and image noise (P=.0049). Similarly, the medium dose CT scan technique had significantly better image quality (P=.0020) and image noise (P =. 0010) compared to the low dose technique. No difference in image quality and image noise existed between the medium and high dose techniques. No difference in visualization of 13 specific anatomic structures existed between any of the dose techniques.

Conclusions

Lower dose CT techniques achieved by flat panel cone beam CT may be an effective and safe alternative to traditional multidetector CT scanners. This imaging modality may help patients avoid unnecessary radiation to sensitive organs.
Inferior Meatus Endoscopy and Treatment for Epiphora
Authors: Rogers Gamwell A , DelGaudio John M
Published: August 2008

Objective

Epiphora can result from obstruction anywhere along the nasolacrimal (NL) system. The inferior meatus (IM) is not routinely evaluated despite the ease of nasal endoscopy. We propose the IM pathology is common in patients with epiphora, and surgery can be directed at the IM.

Methods

Consecutive patients referred for epiphora between July 2006 and July 2007 underwent endoscopic evaluation of the IM. All patients then underwent intervention to address the NL duct orifice obstruction.

Results

There were 14 patients, 11 females, mean age 53 years. Four patients had bilateral epiphora, for 18 total lacrimal systems. Two patients were treated in clinic, one for a dacryolith and one, a thick mucoid plug. At the time of surgery, 4 NL duct orifices were obstructed by a cyst. The remaining 12 nasolacrimal ducts were obstructed by hypertrophied mucosa. In 4, hypertrophic mucosa was found proximal to Hasner's valve, and 3 of these had early recurrent symptoms requiring revision (2 DCR's). 13 of 14 sides with pathology at Hasner's valve had resolution or dramatic improvement with patent NL ducts with inferior meatal treatment alone. Mean follow‐up was 5 months.

Conclusions

Routine endoscopic evaluation of the inferior meatus in epiphora uniformly identified pathology at the NL duct orifice. At the time of surgery, identification of pathology at the NL duct orifice and distal NL duct portends a better outcome with endoscopic treatment of the IM, whereas identification of proximal NL duct obstruction had a poorer outcome with treatment through the IM.
Nasoseptal Flap Takedown in Endoscopic Skull Base Surgery
Authors: Zanation Adam Mikial , Snyderman Carl H , Carrau Ricardo L , Amin Kassam
Published: August 2008

Objective

1) Understand the importance of the nasoseptal flap in endoscopic skull base reconstruction. 2) Learn the techniques and limitations of nasoseptal flap takedowns and reuse during second stage and revision endoscopic skull base surgery.

Methods

Prospective consecutive analysis of CSF leak outcomes with nasoseptal flap takedown and reuse during endoscopic skull base surgery at a tertiary care skull base center.

Results

16 consecutive cases of nasoseptal flap takedown and reuse for endoscopic endonasal intradural tumor surgery were collected prospectively and evaluated for CSF leak outcomes. 10 of these cases were planned second‐stage surgeries and 6 were for revision or recurrent tumors. All 16 cases had intradural tumor extension and intra operative CSF leak. 15 of 16 had successful skull base reconstruction without postoperative CSF leak. One patient required revision endoscopic CSF leak repair and bolstering of the defect with a fat graft on post operative day 3. No flap deaths occurred. Endoscopic skull base reconstructive techniques and limitations of flap takedowns are discussed.

Conclusions

As the limits of endoscopic skull base surgery increases, the limits of endoscopic skull base reconstruction must also increase. The pedicled nasoseptal flap has shown great promise (4% leak rate in over 300 nasoseptal flap skull base reconstructions) at the time of the initial resection. This report illustrates the ability to takedown and reuses the nasoseptal flap in revision cases with great success (94%) and minimal additional nasal morbidity.
Outcome of Endoscopic Sinus Surgery
Authors: Al Badaai Yahya Nasser , Samaha Mark
Published: August 2008

Objective

1) Determine the effect of surgical therapy for Chronic Rhinosinusitis (CRS) on patient quality of life in a tertiary care centre in Quebec. 2) Compare the outcome of endoscopic sinus surgery on patients with different comorbidities.

Methods

Prospective cohort study. Subjects were consecutive patients with a diagnosis of CRS who failed medical treatment and were undergoing Endoscopic Sinus Surgery (ESS). General health (SF‐12 v2) and disease‐specific (chronic sinusitis survey (CSS)) outcomes questionnaires were filled out pre‐operatively and postoperatively.

Results

152 patients were enrolled in a 7‐month period. 120 patients completed the postoperative surveys. The most common co‐morbidity was asthma (40%). 72% had clinical improvement, 12% worsened, and 15% were unchanged. The average improvement of CSS scores was 17%.

Conclusions

Significant improvement in quality of life was achieved after ESS for patients with CRS.
Polymorphisms in the IL22RA1 Gene and Chronic Rhinosinusitis
Authors: Mfuna Endam Leandra , Bossé Yohan , Cormier Chantale , Boisvert Pierre , Boulet Louis‐Philippe , Hudson Thomas J. , Desrosiers Martin
Published: August 2008

Objective

Recently, a pooling‐based genome wide association (pGWAS) scan idenfied the interleukin‐22 receptor alpha 1 (IL22RA1) gene as a promising candidate for chronic rhinosinusitis (CRS). The relevance of this gene in CRS is also substantiated by previous biological studies 1) that stimulation of the gene product increases the innate immune responses in some inflammatory diseases, and 2) a reduced level of the gene transcript in patients with recalcitrant CRS with nasal polyposis. We explore whether single nucleotide polymorphisms (SNPs) in the IL22RA1 gene are associated with CRS.

Methods

DNA extracted from a population of 206 patients with severe CRS and 196 postal‐code matched controls was used. The 23 tagging SNPs in the IL22RA1 gene were selected from positive results in the pGWAS and completed with tagging SNPs from the CEU HapMap dataset and genotyped in our population. The haploview software was used to determine association.

Results

22 SNPs were genotyped successfully with a genotype distribution in agreement with the Hardy‐Weinberg equilibrium. Seven (rs10751768, rs10794665, rs16829225, rs3936073, rs4292900, rs4648936, rs7418238) out of 22 genotyped‐SNPs were significantly associated with CRS (p‐value: 0.0009 to 0.0337; OR: 1.44 to 1.76).

Conclusions

Polymorphisms in the IL22RA1 gene are associated with severe CRS. This may help better understand the pathophysiology of CRS and identify new targets for therapy. Replication in a second population with CRS is in progress to validate these findings.