Diffuse nasal polyposis: postoperative long-term results after endoscopic sinus surgery and frontal irrigation.

Diffuse nasal polyposis remains a challenge despite recent improvements in endonasal surgery. The purpose of this study is to evaluate the results after a radical complete sphenoethmoidectomy with peroperative and postoperative frontal irrigation in cases of diffuse nasal polyposis. In this prospective study, we include 50 consecutive patients with diffuse nasal polyposis suffering from nasal obstruction, anosmia, and other symptoms of chronic sinusitis. All patients were refractory to medical therapy. In each patient an endoscopic complete sphenoethmoidectomy including total excision of all diseased ethmoid mucosa was performed. Preoperative and postoperative frontal irrigation was performed systematically. The patients were followed closely with serial endoscopic examination, and CT scanning was performed between 2 and 3 years after surgery. There were no complications. Thirty-nine of the 50 patients regained satisfactory olfaction. Partial nasal obstruction persisted in four of the 50 patients. Endoscopically, polyp recurrence was noted in 3% of posterior ethmoids, 23% of anterior ethmoids, and 50% of frontal recesses. We conclude that in cases of refractory and extensive nasal polyposis, a total sphenoethmoidectomy with perioperative frontal irrigation followed by long-term postoperative topical steroid therapy provides excellent improvement or cure with safety and reliability.

Staging of chronic hyperplastic rhinosinusitis: treatment strategies.

In 1990 we reported an initial prospective study of 100 patients using a four-stage system for classification of chronic rhinosinusitis. Between January 1988 and July 1992, we used this system in staging an additional 1814 patients, on whom 2980 intranasal sphenoethmoidectomies were performed. In this staging system a protocol trial of medication was given for 2 weeks, followed by axial and coronal computed tomography. Medication consisted of a second-generation cephalosporin antibiotic, usually cefuroxime; a 4-day burst of intraoral steroids, usually prednisone; and an antihistamine decongestant if not contraindicated. The stages of chronic hyperplastic rhinosinusitis included the stages described in the 1990 report (i.e., stage I, single-focus disease; stage II, discontiguous disease throughout the ethmoid labyrinth; stage III, diffuse disease responsive to medication; and stage IV, diffuse disease unresponsive to or poorly responsive to medication). The results of this study have shown that the computed tomography staging system based on computed tomography extent of disease after medical therapy is a simple, easily remembered, and very effective modality for the classification of chronic sinusitis. This system provides a rationale for discussing and planning surgery with patients and physicians and is a convenient reference for the reporting of end results. More importantly, a linear relationship between disease stage and outcomes is demonstrated. This statistically highly significant feature of the staging system provides a firm basis for the production of outcomes after various treatment strategies, particularly ethmoidectomy and the treatment of sinusitis.

Intranasal sphenoethmoidectomy: an evolution of technique.

Intranasal sphenoethmoidectomy was originally used primarily for the provision of adequate drainage of acute and subacute bacterial sinusitis. However, the spectrum of inflammatory sinus disease has changed dramatically since the popularization of broad-spectrum antibiotics, and chronic hyperplastic rhinosinusitis has replaced acute sinusitis as the primary indication for ethmoidectomy. In such cases total or almost total disease removal is crucial to providing long-term drainage and ventilation. We describe several modifications of the Yankauer sphenoethmoidectomy technique that enable the sinus surgeon to provide clearance of disease and excellent drainage for all sinuses by complete marsupialization of the sphenoid, ethmoid, and maxillary sinuses. These modifications include (1) complete rather than partial removal of the middle turbinate, (2) extended middle meatal antrostomy with palatine bone resection to the pterygoid process with delineation of the inferior and medial orbital wall, and (3) introduction of operative endoscopes as adjunctive tools in areas inaccessible to conventional visualization. The current technique and results in nearly 2000 procedures are described.

Staging systems for chronic sinus disease.

A four-stage system is proposed for the classification of chronic hyperplastic rhinosinusitis. The system is comprehensive, simple to use, and has demonstrated extreme clinical usefulness. There is a linear correlation between recurrence rates and stage of disease. The system has virtually mandated treatment strategies for chronic sinusitis. Stage I disease is considered primarily medical, while Stages II, III and IV are surgical. The author's long-standing study is in agreement with Kennedy, Mackey and Lund in their view that radiographic assessment of extent of disease is the major determinant for staging and prognosis. This study, which began in 1988 and has been reported progressively since that time, has proven both useful and accurate for physicians using it, and more importantly has been a boon in explaining to patients the prognosis, needed treatment strategies, and potential outcomes in the treatment of their chronic sinusitis.

Palatal extension of middle meatal antrostomy.

The palatine bone is an important posterior landmark in the performance of ethmoidectomy. This usually unrecognized structure forms the posterior one third of the lateral nasal wall. Resection of a portion of the palatine bone completes the marsupialization of the sphenoethmoidal recess and medial maxilla. It is a major landmark for localization of the sphenopalatine artery at its entrance into the nose. Middle meatal antrostomy is enhanced by removal of the part of the palatine bone that forms the posterior medial wall of the maxillary sinus. In 1110 consecutive sphenoethmoidectomies, marsupialization of the maxillary sinuses has included partial removal of the perpendicular plate of the palatine bone. Patency has been maintained in all of these antrostomies. Pertinent anatomy and surgical technique are reviewed.

Transantral revision of recurrent maxillary and ethmoidal disease following functional intranasal surgery.

Recurring disease in the maxillary sinus, despite inferior meatal antrostomies, has led to the widespread use of middle meatal antrostomy or simple decompression of the natural ostium of the middle meatus in attempts to restore function to the maxillary sinus. We have reported recurrent disease in the maxillary sinus in patients with stage III or stage IV hyperplastic rhinosinusitis in whom attempts at functional surgery of the middle meatus were unsuccessful in reversal of retrograde changes. One hundred patients who had previously undergone intranasal sphenoethmoidectomy with removal of the middle turbinate, decompression of the maxillary ostium, and removal of overt hyperplastic disease of the middle meatus underwent revision transantral ethmoidectomy. All recurrent or residual diseased mucosa was removed, including polyps, occasional mucoceles, and hyperplastic changes that occurred despite patency of a middle meatal maxillary ostium. In many of these patients the maxillary sinus was widely marsupialized secondarily into the posterior nasal vault. While the initial overall polyp recurrence rate after intranasal sphenoethmoidectomy in these patients was as high as 19.2%, the rate of polyp recurrence after transantral revision was less than 5% in from 18 to 48 months postoperatively. The experience in this series suggests that mucosal changes have played a primary role in unsuccessful treatment, independent of whether or not adequate functional egress for maxillary secretion, drainage, or ventilation has been created or restored.(ABSTRACT TRUNCATED AT 250 WORDS)

Benign cystic vs. solid lesions of the parotid gland in HIV patients.

In this study of 13 patients with cystic lesions of the parotid gland, 9 patients were known to be antibody positive for the human immunodeficiency virus (HIV) and 4 were subsequently tested to be positive. All patients had computed tomographic (CT) confirmation of parotid gland cysts. Five patients had fluid aspirates showing high amylase levels. All cystic lesions had lymphoepithelial features and lymphoid histology similar to those seen in HIV infection. This study includes a review of 148 HIV patients reported in the literature, as well as our experience. Of all the reported cases, when gross pathology suggested cystic lesions, the incidence of malignancy was close to 1%. The incidence of malignancy for a solid mass, however, was close to 40%. We propose a nonsurgical management protocol which includes CT scan and needle aspiration with tissue for cytology and fluid for amylase level if possible. Watchful observation is advised for cystic pathology.

The effects of lower lateral cartilage excision on nasal tip projection.

Nasal tip projection is an important defining feature of the nasal profile. Loss of projection is often the bane of the rhinoplastic surgeon. While augmentation techniques for maintaining or increasing tip projection are useful in selected patients, the majority of rhinoplasties rely on excision of cartilage, particularly cartilage of the cephalic border of the lower lateral crura, to produce the desired cosmetic result. The purpose of this study was to measure the effects of lower lateral cartilage excision on nasal tip projection resulting from three common forms of nasal tip surgery. These techniques included cephalic border resection without vertical dome division, cephalic border resection with vertical dome division, and cephalic border resection with dome division and suture reapproximation of the mesial crura, the so-called "Goldman tip." Despite the fact that overall excellent results were obtained and loss of projection was rarely a noticeable feature, a measurable loss of projection can be seen in all but one case in this series. Although loss of tip projection is usually acceptable due to the masking effect, the concurrent reduction in dorsal nasal height, loss of projection must be anticipated in excisional techniques of the lower lateral cartilage.

Computed tomography staging of the paranasal sinuses in chronic hyperplastic rhinosinusitis.

In this study, the computed tomography scans of 100 patients with chronic hyperplastic rhinosinusitis were reviewed to establish a clinical staging system. Fourteen percent of the patients were classified as Stage I (single-focus disease); 36% as Stage II (multifocal disease responsive to conservative therapy); 32% as Stage III (diffuse disease partially responsive to medication); and 16% as Stage IV (diffuse disease associated with bony changes and poorly responsive to conservative treatment). The incidence of recurrent or persistent disease ranged from 13% for Stage II to 30% for Stage IV. Stage I and III patients had 13% and 18% recurrence rates, respectively. Computed tomography staging is shown to be useful in outlining operative strategies and is a reliable prognosticator of the disease process.

The role of computed tomography in revision sinus surgery.

In this retrospective study, 34 patients with recurrent hyperplastic rhinosinusitis who subsequently underwent further surgical intervention were evaluated with computed tomography scans in order to assess the role of computed tomography in revision sinus surgery. Fourteen of these patients had originally undergone sphenoethmoidectomies, 8 had endoscopic sinus surgeries, 6 had Caldwell-Luc operations, and 6 had intranasal antrostomies. Computed tomography scan was instrumental in correctly identifying the site and reasons for failure and assisted in localizing further surgical intervention to the appropriate sites in 30 patients. The indications for computed tomography and revision surgery are discussed and defined.

Intranasal and transantral ethmoidectomy: a 20-year experience.

Ethmoidectomy is an operation that has engendered controversy concerning the best route of surgical access. The purpose of this study was to present the results of the authors' experience in more than 1300 intranasal sphenoethmoidectomies and transantral sphenoethmoidectomies performed over a 20-year period. The authors contend that the most effective ethmoidectomy is the most complete ethmoidectomy and have previously presented a case for ethmoid marsupialization. Polyp recurrence rates of less than 20% and a major complication rate of less than 1% were reported in this study.

Infratemporal fossa and lateral skull base dissection: long-term results.

In 1981, we described a new surgical technique featuring en bloc removal of infratemporal fossa malignancies. This approach offered a systematic resection of cancers in this region and was designated "stylohamular dissection" because the medial boundary of the bloc is surgical plane between the styloid process and the hamulus of the pterygoid. All structures lateral to this plane are removed, sparing the internal carotid artery. Since 1977, twenty infratemporal fossa and lateral skull base dissections have been performed for palliation of metastatic or recurrent disease in the infratemporal fossa. Most patients obtained palliation of trismus, facial pain, or relief from an unmanageable ulcerating lesion. This technique offers improved average disease-free intervals, as well as enhanced survival rates compared to non-en bloc resections. A summary of the case presentations, survival statistics, and surgical technique with detailed cadaver dissections are presented.

The surgical treatment of snoring: a patient's perspective.

An increasing number of loud snorers seek medical attention because of the social impact of snoring as well as its association with sleep apnea. Uvulopalatopharyngoplasty is reported to reduce or eliminate snoring in the majority of patients; however, little data are available to document the procedure's success. From February 1987 through August 1988, 125 patients underwent uvulopalatopharyngoplasty for habitual snoring; many of these patients had also documented sleep apnea. Of the 74 patients who responded to a postoperative questionnaire, 64 (86.48%) indicated that their snoring was either completely eliminated or markedly reduced. Only two patients reported significant side effects.

The surgical management of advanced malignancies of the parotid gland.

Advanced malignancies of the parotid gland frequently invade the parapharyngeal space and the infratemporal fossa. The majority of these lesions have not been cured by surgery and/or radiotherapy, and palliation or cure can only be achieved by en bloc resection of this region. Stylohamular dissection is a systematic method for en bloc resection of the infratemporal fossa and lateral skull base. From January 1980 until December 1987, 18 patients with advanced parotid malignancies underwent stylohamular dissection. Pathologic examination revealed the following diagnosis: adenocarcinoma (7), squamous cell carcinoma (5), high-grade mucoepidermoid carcinoma (2), metastatic adenocarcinoma (1), fibrosarcoma (1), malignant hemangiopericytoma (1), and melanoma (1). Nine patients in this series are alive after a mean follow-up period of 3.5 years (range 1 to 9 years). Three patients are dead of uncontrolled local disease and three of distant metastasis. Three patients died of unrelated causes. All patients except the three who had uncontrolled disease experienced marked palliation from their pain, trismus, and unmanageable ulcerative lesions after surgery. The operative morbidity was relatively low.

Paranasal sinus etiology of headaches and facial pain.

The otolaryngologist is obliged to consider chronic headache attacks because it is probable that people afflicted with chronic headache claim to have "sinusitis" more than any other related chief complaint. While only a small percentage of these patients actually have headaches of sinus etiology, sinusitis must be differentiated from all other forms of headache. Otolaryngologists who are primarily interested in headache may require less consultation with neurologic and neurosurgical colleagues than otolaryngologists who are primarily interested in sinus surgery and the treatment of sinusitis. In any case, all otolaryngologists should be conversant with the causes of headache and well trained in the treatment of headaches, particularly those related to the paranasal sinuses.

The role of standard technique in modern sinus surgery.

This article reviews the most commonly performed intranasal and extranasal sinus operations. The indications, complications, and functional results of each are presented. Endoscopic approaches should be used in conjunction with standard techniques in order to supplement and improve the efficiency of standard techniques of sinus surgery.

Isolated sphenoid sinus disease.

Forty-three cases of isolated sphenoid sinus disease were reviewed. In 33 cases, headache was a presenting symptom. Seven of 29 cases of inflammatory disease and nine of 13 patients with tumors of the sinus presented with cranial nerve findings. When nonspecific visual disturbances were eliminated, two of 29 cases of inflammation and eight of 13 cases of tumors of the sphenoid sinus had cranial nerve deficits. Ten of 12 CT scans performed on patients with tumors of the sinus demonstrated bony erosion or perisinus extensions. This was not found in any of the 27 scans of patients with inflammatory disease. A thorough cranial nerve examination and a CT scan should be performed early in patients who present with vague and unusual headaches.