What is the proper role of oral antibiotics in the treatment of patients with chronic sinusitis?

PURPOSE OF REVIEW: Chronic rhinosinusitis is a common illness for which systemic antibiotics are frequently prescribed, although high-level evidence for this practice is largely lacking. We review the available literature addressing the proper role of oral antibiotics in the treatment of chronic rhinosinusitis. RECENT FINDINGS: Chronic rhinosinusitis is an incompletely understood disease process for which the role of antibiotics remains difficult to define despite its historical prominence. There is no high-level evidence to support the use of oral antibiotics in chronic rhinosinusitis. Placebo-controlled studies of macrolide antibiotics indicate either no effect or limited degrees of improvement. Recent literature has identified that sinusitis refractory to medical therapy may represent an odontogenic source, and this should be addressed by dental surgery rather than by additional antibiotics. SUMMARY: Oral antibiotics can be prescribed most confidently for the management of chronic rhinosinusitis when purulent exacerbations of disease are detected endoscopically and antibiotic choices are directed by culture. Long-term macrolide antibiotic therapy, acting through immunomodulatory pathways, may be of benefit in chronic rhinosinusitis patients with low immmunoglobulin E levels. Odontogenic sources of sinusitis are best detected by a computed tomography scan and treated through dental surgery. There is no high-level experimental evidence to support the use of oral antibiotics in the management of chronic rhinosinusitis. The challenge continues to be the inability to perform double-blinded studies, as both patients and physicians are generally unwilling to participate in chronic sinusitis treatment studies with a placebo arm, given the deep-seated belief of oral antibiotic efficacy in treatment.

Angiomatosis of the paranasal sinuses.

Angiomatosis is a rare benign lesion of the head and neck that can be mistaken for either a vascular malformation or malignant disease as a result of its infiltrative nature. The recurrence rate of angiomatosis requiring surgery is reported to be >90%, and as such the otolaryngologist treating this condition should endeavor to remove all disease during the first operation while maintaining a high level of suspicion for recurrence during postoperative surveillance. This case represents the first report of angiomatosis involving the nose and/or paranasal sinuses, and extends the differential diagnosis of sinonasal tumors, of which the otolaryngologist must be aware. A description of the surgical care and postoperative surveillance recommendations is detailed in this first reported case of angiomatosis of the paranasal sinuses.

Paranasal sinus exostoses: possible correlation with cold temperature nasal irrigation after endoscopic sinus surgery.

Exostoses of the external auditory canal (EEAC) are a commonly encountered clinical exam finding; however, exostoses in other locations are vanishingly rare. The postoperative paranasal sinuses are penetrated with cold water solutions, the reputed etiological agent for EEAC, and development of exostoses in this unexpected location may be observed endoscopically. The surprising appearance of these protuberant lesions within the sinuses could be mistaken for more ominous processes, subjecting the patient to biopsy, surgery, or unnecessary medical therapy. The radiologic appearance of exostoses within the paranasal sinuses is herein reported for the first time, and care is taken to distinguish these bony lesions from the osteoneogenesis of chronic inflammation.

The spectrum of isolated congenital nasal deformities resembling the cleft lip nasal morphology.

OBJECTIVE: To define the intrinsic (hypoplasia) and extrinsic (deformational) contributions to congenital nasal deformities and the potential of a carrier state for orofacial clefting. METHODS: Retrospective case series. RESULTS: The factors affecting 4 congenital nasal deformities are postulated after contrasting the patient's characteristics. CONCLUSIONS: The spectrum of congenital nasal deformities includes those that resemble the cleft lip nasal deformity, but careful inspection is needed for proper classification. Classifying congenital nasal deformities can be difficult in part due to the highly variable normal range. The most minor form of the typical unilateral cleft lip nasal deformity is the microform cleft. The potential of an isolated cleft lip nasal deformity without obvious cleft lip has been previously suggested to represent a carrier state for orofacial clefting. Definitive genetic studies and continued anthropometric documentation in relatives of patients with orofacial clefts are needed if we are to uncover previously unidentified associations, and a potential carrier state.

Analysis of flap tension in surgical rejuvenation of the midface: a cadaver study.

OBJECTIVE: To determine the flap tension present for 2 different surgical approaches for midface lifts and whether a gingivobuccal incision for release of the midface periosteum will diminish the resultant load on the midface flap. STUDY DESIGN: Cadaver study. SETTING: Anatomy laboratory at the University of Florida. SUBJECTS AND METHODS: Twelve fresh-frozen cadaver heads are subjected to a transblepharoplasty (TB) approach on one side of the cadaver head while a transtemporal (TT) approach is performed on the contralateral side. The tension (grams) generated by moving the midface flap a distance of 1.03 cm is recorded by a digital load cell. A gingivobuccal incision is made on each side to allow transoral periosteal release (TOPR) of the midface flap, and the experiment is repeated. Three trials are performed for each operation, and the average load is calculated. A paired t test is applied. RESULTS: The tension resulting from the TT approach (172 g) was not found to be significantly different from that of the TB approach (179 g; P = .75). Significant differences in the resultant tension were not appreciated when comparing standard techniques to TT with TOPR (141.5 g; P = .27) or for TB with TOPR (164.1 g; P = .45). DISCUSSION: An experimental method is described for determining flap tension in facial rejuvenation surgery. No significant difference is found between flap tensions generated in the TB and TT approaches to the midface.

The efficacy of rhinoplasty alone in facial rejuvenation.

PURPOSE: The aim of the study was to demonstrate whether rhinoplasty alone is a rejuvenating procedure for the aging face. MATERIALS AND METHODS: Photographs of the right profile of 48 white females older than 55 years were recorded using standardized techniques. Each of the subjects' noses underwent computer-simulated rhinoplasty to conform to aesthetic canons of the ideal nose. Forty-eight evaluators, blinded to the purpose of the study, were shown either the natural right profile or the morphed image. The evaluators then estimated subject age. RESULTS: Evaluators were divided into younger and older cohorts. Computer-simulated rhinoplasty alone did not prove to be statistically rejuvenating (Hotelling-Lawley Trace, P = .203). This finding held true for both the younger and older cohort of evaluators (P = .98). Although not statistically significant, evaluators estimated the age of the morphed images to be 6.5 years (mean) younger than actual age for all subjects. CONCLUSIONS: Rhinoplasty alone is not statistically rejuvenating in the profile view of white females older than 55 years. However, age estimation may be less accurate than was hypothesized for the profile view, possibly because of other visual queues.

Temporalis muscle flap for reconstruction of skull base defects.

BACKGROUND: The temporalis muscle flap (TMF) is a valuable reconstructive technique utilized in a variety of challenging defects. However, its use for repair of skull base defects is less commonly reported. METHODS: A retrospective chart review was conducted for 35 patients who underwent reconstruction of skull base defects between March 1999 and July 2006 at a tertiary referral hospital. Patients with skull base defects after trauma or extirpative surgery underwent reconstruction with a TMF. The measured outcomes were as follows: defect size/location, need for additional flaps, bone necrosis, hardware exposure, dehiscence, cerebrospinal fluid (CSF) leak, and meningitis. RESULTS: Forty-two patients underwent reconstruction with a TMF, and 35/42 patient records were available for review. No flap failures, 1 transient CSF leak, 3 hardware exposures distant from the temporalis recipient site, and 3 hydroxyapatite cement infections or foreign body reaction were observed. CONCLUSION: The TMF represents a versatile reconstructive technique employed with minimal morbidity and a low complication rate to repair defects of the skull base.

The secondary correction of post-traumatic craniofacial deformities.

OBJECTIVE: To analyze the aesthetic and functional outcomes in a large series of patients who underwent secondary correction of post-traumatic craniofacial deformities (PTCD) and to highlight the underlying principles and formulate treatment guidelines. METHODS: A single surgeon's retrospective case series of 57 patients who underwent correction of PTCD. OUTCOME MEASURES: Evaluation by multiple surgeons who assessed aesthetic results and functional parameters after secondary correction of PTCD. RESULTS: A good to excellent aesthetic outcome was achieved in the majority of patients. Traumatic telecanthus, enophthalmos, and occlusal deformity were the deformities most refractory to secondary correction. Aesthetic results were adversely affected by the severity and number of pre-existing abnormalities and by the presence of established deformities (beyond 6 to 12 months). CONCLUSIONS: The basic principles of treatment include an initial major osseous reconstructive surgery to restore an anatomically correct craniofacial architecture followed by selective ancillary procedures to address soft tissue deficits and functional deformities. Soft tissue deformity is the major deterrent to achieving an ideal outcome.

Objective assessment of the accuracy of computer-simulated imaging in rhinoplasty.

OBJECTIVE: The objective of the study was to evaluate the accuracy by which computer-simulated rhinoplasty images reflect surgical results in 6-month postoperative photographs. METHODS: We performed a retrospective, objective evaluation of 5 features of the facial profile in the computer-simulated images and in the 6-month postoperative photographs of 36 rhinoplasty patients. Data recorded for the nasolabial angle, nasofrontal angle, columella tip angle, columella/infratip lobule ratio, and an established method of assessing tip projection were subjected to statistical analysis by 2-tailed t test and analysis of variance testing. RESULTS: Simulated and actual measurements of columella tip angle were found to be significantly different (P = .021). The set of measurements taken from computer-simulated images at the nasolabial angle (P = .301), nasofrontal angle (P = .471), columellar/infratip lobule ratio (P = .402), and tip projection ratio (P = .547) were not statistically different from the respective measurements recorded from the 6-month follow-up images. CONCLUSIONS: No significant difference was found between the measurements recorded from computer-simulated images and those recorded from 6-month postoperative photographs in 4 of the 5 features of the facial profile studied. The accuracy and predictive value of computer-simulated images is demonstrated and quantified for the first time.

Comparison of closed reduction alone versus primary open repair of acute nasoseptal fractures.

OBJECTIVE: Nasoseptal injuries have traditionally been treated via closed reduction. Historically, the high incidence of postreduction deformities has led some surgeons to consider alternative approaches to obtain superior results. Here we compare simple closed reduction versus primary open repair of the nasoseptal fracture. STUDY DESIGN: This was a prospective study of 40 consecutive patients treated with simple closed reduction of their combined nasal bone and septal fracture versus 40 patients treated with closed reduction of their nasal bone fracture and open treatment of the septum. Group outcomes were then compared. RESULTS: In the closed reduction group, 60% had significant postoperative septal deviation, whereas only 12.5% suffered from residual septal deformity in the open group. This resulted in a statistically significant reduction (p < .01) of patients requiring a second operation to formally address the septum. CONCLUSION: By addressing the septum through an open approach, a statistically significant reduction in the number of patients requiring revision rhinoplasty was achieved.

Asymmetric sensorineural hearing loss evaluation with T2 FSE-MRI in a public hospital.

CONCLUSIONS: T2-weighted fast-spin echo magnetic resonance imaging (MRI) can be an economically beneficial protocol for screening patients with asymmetric sensorineural hearing loss without other neurologic findings in a public hospital population. OBJECTIVE: The goal of this study was to determine if fast spin echo T2 MRI is similar to gadolinium-enhanced MRI in evaluating asymmetric sensorineural hearing loss in a county hospital population. PATIENTS AND METHODS: This was a retrospective chart review of all outpatients seen at a public hospital, comprising patients with no other cranial nerve findings who underwent gadolinium-enhanced MRI of the internal auditory canal and brain between January 2002 and September 2003. Patients with >15 dB difference in hearing at one frequency or 10 dB hearing difference at two frequencies underwent gadolinium-enhanced MRI scan with FSE T2 sequence as part of the examination protocol. RESULTS: A total of 146 patients were identified who met all the inclusion criteria for the study. Of the 146 MRI scans performed, abnormalities were seen on 71 of them, the majority of which were inconsequential. No acoustic neuromas were identified in our study population. Cost savings of over 100,000 dollars would have been realized if only T2 FSE protocols had been used.

Kaposiform hemangioendothelioma: case report and literature review.

We report the identification of a kaposiform hemangioendothelioma (KH) in the oropharynx of a 3-year-old boy. This is a rare endothelial-derived spindle cell neoplasm affecting children and early adolescents with features common to capillary hemangioma and Kaposi sarcoma. Nine cases of head and neck KH have been reported, this being the first in the otolaryngology literature. Our patient underwent wide local excision and has remained tumor free for over 1 year. KH should be considered in the differential diagnosis of a vascular lesion demonstrating unexpected behavior from that of a hemangioma.

Minimally invasive transoral catheter-assisted drainage of a danger-space infection.

We report the case of a 3-year-old boy who was brought to the emergency department for evaluation of a prolonged upper respiratory infection and diminished neck movement. Computed tomography identified a unilocular abscess extending from the level of C2 inferiorly to the diaphragm at the level of the T9 vertebral body. We successfully treated this transcervical, transthoracic infection surgically via a transoral approach to the retropharyngeal abscess combined with catheter drainage and irrigation of the abscess cavity at a depth of 13 cm. At 25 months of follow-up, the patient exhibited no evidence of recurrent disease or postsurgical complications. In this article, we describe our minimally invasive technique for managing unusual deep-space neck infections in children.