Delayed symptomatic cerebral vasospasm after transsphenoidal resection of pituitary adenoma.

Not required for Clinical Vignette.

Frontal Angle: A New Predictor of Difficulty in Endoscopic Frontal Sinus Surgery-A Preliminary Computed Tomography Study.

OBJECTIVES: The possibility of visualization of the frontal sinus during endoscopic surgery depends on 3-dimensional configuration of the frontal sinus opening (FSO). We aimed to determine the prevalence of unfavorable angulation of the lower part of the posterior wall of the frontal sinus and its relation to FSO diameter. METHODS: One hundred and twenty-eight computed tomography (CT) scans were retrospectively reviewed to measure (1) the angle between the nasal floor and the plane tangent to the posterior table of the frontal sinus above the most posterior aspect of the anterior buttress (frontal angle, FA) and (2) dimensions of the FSO. RESULTS: The FA ranged from below 30° to 90°. Nearly 13% of sinuses (16.4% of patients) showed FA about 90°, which should enable good visualization of the sinus with the 30° scope after opening and clearing the frontal recess, while 4% (6.25% of patients) showed FA ≤ 30°. The anterior-posterior diameter (A-PD) was below 5 mm in 17.6% of sinuses (26.6% of patients). There was a significant correlation between FA and A-PD. Unfavorable combination of FA and A-PD (<45°, <5 mm) was present in 5.2% of sinuses (8.6% of patients), and extremely unfavorable combination (<30°, <5 mm) in 0.8% (0.8% of patients). CONCLUSIONS: The FA shows great interindividual variability, which is very likely to reflect the possibility of inspection of the frontal sinus. This implies a need for further prospective clinical studies to validate FA as a predictor of difficulty in frontal sinus surgery.

Sphenomaxillary Plate: Landmine or Landmark?

OBJECTIVES: Sphenomaxillary plate (SMP) is an inconstant bony septum separating the maxillary and sphenoid sinuses. Neglecting the SMP during endoscopic sinus surgery may lead to mistaking the sphenoid sinus for the posterior ethmoid cell with potentially dangerous consequences. However, its proper identification may allow planned sphenoidotomy through the posterior wall of the maxillary sinus or to enlarge transnasal or transethmoidal sphenoidotomy. The aim of this study was to evaluate (1) the incidence and morphology of the SMP and (2) possibility and safety of trans-SMP sphenoidotomy. METHODS: In the radioanatomical part of the study multiplanar reconstruction analysis of 117 consecutive paranasal sinus CT scans was conducted. In the clinical part of the research, trans-SMP sphenoidotomy was performed in consecutive patients operated on for chronic rhinosinusitis. RESULTS: The SMP was found in 25% of sides (34% of patients). It was constantly located superolateral to the posterior insertion of the middle turbinate. The SMP formed the prominence on the posterior wall of the maxillary sinus that could be identified using volume rendering in 11% of sides (19% of patients). 30 trans-SMP sphenoidotomies were performed in 18 patients. The SMP prominence was identified in 15 sides. In absence of SMP prominence, identification of the SMP was still possible using other anatomical landmarks. CONCLUSIONS: The SMP is present in over 30% Caucasian subjects at least on one side. Sphenoidotomy through the SMP is feasible and safe.

Impact of pre-transplantation sinus abnormalities assessed by Lund-Mackay scoring system on sinusitis occurrence after allogeneic hematopoietic cell transplantation in acute leukemia patients.

INTRODUCTION: Screening sinonasal evaluation is routinely performed before allogeneic hematopoietic cell transplantation (allo-HCT), however, data supporting such evaluation is inconsistent. O b j e c t i v e s: Assessment of the utility of screening sinonasal evaluation with computed tomography (CT). METHODS: A retrospective analysis of acute leukemia patients who underwent allo-HCT, for whom screening sinonasal CT scans were reevaluated, and for whom Lund-Mackay score (LMS) was calculated. R e s u l t s: Forty-eight patients, the median age at allo-HCT 38 years (18-58), 52% males, were included. 79% had acute myeloid leukemia (AML), 21% acute lymphoblastic leukemia (ALL). Conditioning intensity was myeloablative in 96% of patients, 21% of patients received total body irradiation. 19% of patients had a history of sinusitis before allo-HCT. Screening sinus CT was performed a median of 22 days before allo-HCT. The median LMS was 1 point (0- 10). The severity of sinus abnormalities was: no abnormalities (31%), mild (67%), moderate (2%), severe (0%). Mucosal thickening was the most frequent abnormality (69%). Eleven patients experienced sinusitis after a median of 93 days (11-607) after allo-HCT. 1-year cumulative incidence of sinusitis was 22%. No threshold of LMS and no type of sinus abnormalities were correlated with sinusitis development after allo-HCT. Mild sinus disease at screening did not negatively impact survival in comparison to no sinus disease. C o n c l u s i o n s: Despite the fact, that majority of analyzed patients had either no or mild sinus disease at screening a significant proportion of patients developed sinusitis after allo-HCT. Evaluation of LMS before allo-HCT did not help predict the development of sinusitis after the procedure.

Endoscopic combined middle and inferior meatal antrostomies approach in treatment of maxillary sinus inverting papilloma.

INTRODUCTION: Endoscopic medial maxillectomy is currently the most commonly used endoscopic approach to the maxillary sinus inverting papilloma. The possible complications of this procedure include epiphora, crusting and empty nose syndrome. Another method, a prelacrimal recess approach, enables preservation of the nasolacrimal duct and inferior nasal turbinate, but offers limited possibility of postoperative endoscopic follow-up. AIM: To evaluate the combined middle and inferior meatus antrostomy approach to treat the maxillary sinus inverting papilloma. MATERIAL AND METHODS: A retrospective assessment of the medical records of consecutive patients operated on due to the maxillary sinus inverting papilloma in a single centre was performed. RESULTS: Fourteen patients operated on using combined antrostomies, with a follow-up of 2 years, are presented. In 2 patients, the tumor involved the prelacrimal recess. One of these patients was successfully operated on using combined antrostomies. In the second patient combined antrostomies were accompanied by a prelacrimal recess approach. None of the 14 patients had intraoperative complications. No recurrence was observed. No drying, empty nose syndrome, lacrimation, floppy turbinate or mucus recirculation was observed. Two patients complained of permanent cheek numbness. Follow-up endoscopy was easily performed with a rigid endoscope through both antrostomies in all patients except one. CONCLUSIONS: Combined antrostomies appear effective to treat the maxillary sinus inverted papilloma. They are associated with minimal invasiveness and complications and enable easy endoscopic follow-up. In patients with prelacrimal recess involvement, it can be supplemented by the prelacrimal recess approach or, if needed, converted to an endoscopic Denker procedure.

Osteoma involving the olfactory groove: evaluation of the risk of a CSF leak during endoscopic surgery.

PURPOSE: The olfactory groove (OG) is a common site of iatrogenic cerebrospinal fluid (CSF) leak during endoscopic sinus surgery. We aimed to evaluate the prevalence of CSF leak during endoscopic removal of osteomas involving the OG and identify CT findings indicating increased risk of this complication. METHODS: A retrospective review was conducted of patients operated on for frontoethmoidal osteoma from 11 years in a single institution. A retrospective review of the literature, 1999 to 2019, of perioperative complications in patients operated on for frontoethmoidal osteoma using endoscopic or combined approaches. RESULTS: Case series: 73 patients were identified including 17 with the OG involvement. The only case of CSF leak occurred in a patient with spongious part of osteoma at the OG. Among six osteomas with spongious component at the OG, one was detached and five had to be drilled down, leaving a small remnant in four. In contrast, all the 11 osteomas with ivory part at the OG were safely detached and completely removed from the OG after debulking. The prevalence of CSF leak was not statistically different between the patients without and with involvement of the OG. Systematic review of the literature: Among the 273 identified patients there were 8 cases of intraoperative CSF leaks (3%) including 2 from the OG (0.7%). CONCLUSION: Involvement of the OG does not significantly increase the risk of intraoperative CSF leak. However, this risk may be increased in patients with the spongious part of the tumor attached to the OG.

Sphenoid sinus septations and their interconnections with parasphenoidal internal carotid artery protuberance: radioanatomical study with literature review.

INTRODUCTION: Internal carotid artery (ICA) injury is the most dangerous and life-threatening complication in patients operated on due to parasellar tumors via a minimally invasive endoscopic endonasal approach. Sphenoid septal attachment to the ICA protuberance within the sphenoid sinus was found to be one of the anatomical risk factors for ICA injury during transsphenoidal surgery. AIM: To determine the relationship between the sphenoid sinus septa and the parasellar or paraclival internal carotid artery prominence based on our own material and a literature review. MATERIAL AND METHODS: The axial plane scans of computed tomography angiography and a literature review of previously published papers on the septum variation and its connection with the ICA prominence are provided. RESULTS: Out of 100 sphenoid sinuses, 49 (49%) had at least one septum inserted at the ICA prominence. In the majority of cases 42 (86%) one septum was inserted at the prominence of one of the ICAs. In 7 (14%) cases, two separate septa were inserted at the prominences of both ICAs. Patients with multiple septa and those having an incomplete septum were at higher risk of at least one of them being inserted at the ICA prominence within the sinus. Including cases from the literature review, the average number of septa per patient was 1.42. The risk of intersection between the septum and the ICA prominence was 32%. CONCLUSIONS: A significant percentage of the intrasphenoidal septa are inserted at the sphenoidal ICA protuberance.

Three-dimensional computed tomography analysis of frontoethmoidal cells: A critical evaluation of the International Frontal Sinus Anatomy Classification (IFAC).

OBJECTIVES: Two major classifications of frontoethmoidal cells, Lee and Kuhn and the IFAC (International Frontal Sinus Anatomy Classification), distinguish anterior, posterior and medial cells. The European anatomical position paper includes also lateral cells. According to the IFAC, anterior cells push the frontal sinus drainage pathway (FSDP) medially, posteriorly or posteromedially. Posterior cells push the FSDP anteriorly. The only medial cell, pushing the FSDP laterally is the frontal septal cell, which is attached to or located in the interfrontal sinus septum. The aim of this study was to verify the IFAC and characterise cells, which are inconsistent with this classification. DESIGN: A radioanatomic analysis. SETTING: Tertiary university hospital. PARTICIPANTS: One hundred and three Caucasian adult patients with no inflammatory changes in paranasal sinuses CT. MAIN OUTCOMES MEASURE: Results of assessment of multiplanar reconstruction of thin slice CT. RESULTS: Two types of cells that cannot be classified using the IFAC were found: (a) Lateral cells extending between the skull base and the anterior buttress, pushing the FSDP anteromedially or medially, present in 34 (16.5%) of the sides, (b) Paramedian cells: medially based, not adjacent to the interfrontal septum, pushing the FSDP laterally and posteriorly, present in 33 (16%) of sides. Suprabulla cells and suprabulla frontal cells were found to push the FSDP in directions other than anterior 28% and 31% of the time respectively. CONCLUSIONS: Neglecting lateral and paramedian cells may lead to inconsistent results between radioanatomical studies and impede communication between surgeons. They should be included in existing classifications of frontoethmoidal cells.

Lateral frontoethmoidal cell obstructing frontal sinus drainage pathway - report of six cases.

The European Anatomical Position Paper on the Anatomical Terminology of the Internal Nose and Paranasal Sinuses distinguishes anterior, posterior, medial and lateral frontoethmoidal cells. The lateral cells have not been characterized yet. Other classifications (Lee and Kuhn, International Frontal Sinus Anatomy Classification) neglect them. The aim of this study is to describe lateral frontoethmoidal cells in rhinosinusitis patients. METHOD: Analysis of medical records and computed tomography (CT) examinations using multiplanar reconstruction with adjustable planes. The lateral cell extending between the frontal beak and the skull base pushing the frontal sinus drainage pathway medially/anteromedially was identified in 6 patients. These cells could not be classified as anterior, posterior or medial according to existing classifications. Four patients were operated on previously due to sinonasal symptoms. The lateral frontoethmoidal cell is an underestimated anatomical variation that may contribute to the persistence of inflammatory disease and can be easily overlooked preoperatively.

Extended draf IIb procedures in the treatment of frontal sinus pathology.

OBJECTIVES: Draf IIb approach provides wide, unilateral access to the frontal sinus. This approach can be extended without destruction of the contralateral frontal sinus drainage pathway, performed during Draf III (modified Lothrop) procedure. There is limited data in the literature regarding the use of modified Draf IIb procedures. METHODS: Patients treated with extended Draf IIb procedures in a single center were retrospectively assessed. RESULTS: Ten patients were identified, including 2 cases of osteoma, 1 inverted papilloma, 1 carcinoma, 5 mucoceles, and 1 chronic rhinosinusitis patient. Six patients had undergone prior surgery, including external procedures in 3 cases. Modifications of Draf IIb were classified as the following: removal of the anterosuperior nasal septum adjacent to the nasal beak, removal of the intersinus septum, and a combination of the above-mentioned methods (upper nasal septum and intersinus septum removal). There were 3 patients operated on with type 1 modification, one patient with type 2 modification, and 6 patients with type 3 modification. There were no perioperative complications. CONCLUSION: In selected cases, extended Draf IIb procedures are safe and effective in the treatment of frontal sinus disease.

Hidden unilateral aplasia of the frontal sinus: a radioanatomic study.

BACKGROUND: Hidden unilateral frontal sinus aplasia is the absence of 1 frontal sinus with increased pneumatization of contralateral sinus toward the aplastic side. It may give the false impression of the presence of 2 separate frontal sinuses, creating potential for complications during the surgery. The aim of this study was to evaluate the prevalence and morphology of this anatomical variation using multiplanar reconstruction of computed tomography (CT) results. METHODS: A total of 305 CT examinations were analyzed. Hidden unilateral frontal sinus aplasia was defined as lack of pneumatization of 1 frontal sinus beyond the level of the orbital roof, with increased pneumatization of the contralateral sinus, extending to the sagittal plane, crossing the lamina papyracea on the side of the aplastic sinus. RESULTS: Eleven patients (3.6%) with hidden unilateral frontal sinus aplasia were identified, 5 on the left and 6 on the right side, in 5 female and 6 male patients. Twenty-four (7.8%) patients with "regular" frontal sinus aplasia (without hyperplastic contralateral frontal sinus) were found, 4 with bilateral aplasia and 20 with unilateral aplasia. CONCLUSION: Hidden unilateral aplasia of the frontal sinus is a relatively uncommon anatomical variation. Its presence should be considered during routine preoperative CT evaluation because it poses the risk of intraoperative complications.

Asymmetry of the anterior skull base at the level of frontal ostium, a radioanatomical study.

BACKGROUND: Radioanatomical studies have shown that the ethmoid roof is asymmetric in 10 to 40% of individuals. The right ethmoid roof has been found on average to be lower compared to the left. The aim of this study was to extend existing results by assessing asymmetry between the right and left anterior skull base at the level of the frontal ostium. METHODOLOGY: Curved multiplanar reconstruction was used to analyse 247 consecutive paranasal sinus CT scans. The corresponding left and right parasagittal profiles of the skull base marked from the anterior ethmoidal artery to the level of the orbital roof were superimposed and compared. RESULTS: Asymmetry greater than 1 mm was found in 87% of patients, greater than 2 mm in 40.5% of patients, and greater than 3 mm in 8% of patients. The prevalence of the patients with lower skull base on the right side was greater than those with lower skull base on the left side at a ratio of more than 2:1. CONCLUSION: Skull base asymmetry in the region of the frontal ostium is observed in a large percentage of the population and may be a potential source of complications during endoscopic sinus surgery.

Endoscopic transnasal management of sinonasal malignancies - our initial experience.

INTRODUCTION: Malignant tumors of the paranasal sinuses are traditionally managed through external approaches. Advances in endoscopic transnasal surgery have allowed for the endoscopic treatment of some of these tumors. AIM: To present the results of treatment of a series of patients with paranasal sinus malignancies treated with an endoscopic approach at a single institution. MATERIAL AND METHODS: The data on tumor type, operative technique, perioperative complications and postoperative course were analyzed. RESULTS: Eleven patients meeting the inclusion criteria were identified. The histopathology was as follows: malignant melanoma in 3 patients, squamous cell carcinoma in 2, adenocarcinoma in 2, poorly differentiated carcinoma in 1, hemangiopericytoma in 1, adenoid cystic carcinoma in 1 and fibrosarcoma in 1. There were no severe perioperative complications with the exception of 1 case of cerebrospinal fluid leak, which was successfully closed. The mean observation period was 13.5 months. One of the patients died of disease, another was lost to follow-up, and one was reoperated on due to recurrence. The remaining 8 patients are alive with no signs of recurrence. CONCLUSIONS: Our initial experience seems to confirm results obtained by other authors indicating that in selected cases endoscopic surgery of sinonasal malignancies is similarly effective as external approach surgery.

Effect of the nasal cycle on congestive response during bilateral nasal allergen provocation.

BACKGROUND: Bilateral nasal allergen provocation usually produces more pronounced obstruction of one nasal passage. It was found that this could be related to the stage of the nasal cycle before the provocation. OBJECTIVE: To discover whether the stage of the nasal cycle is decisive for asymmetry in congestive response observed during bilateral allergen nasal provocation. methods. Two bilateral nasal allergen provocations were performed in a group of 26 pollen-sensitive volunteers. Acoustic rhinometry measurements were taken during the nasal cycle, and then after the provocation. A cross-sectional area at the level of the inferior turbinate (CSA-2) was measured. Consecutive challenges were performed in the opposite phase of the nasal cycle: the side which had been wide just before the first challenge, was narrow before the second provocation. RESULTS: Asymmetry in CSA-2 reduction between the nasal passages was observed in most cases. Significant difference was observed between mean CSA-2 reduction rate (reactivity) of the side that responded with greater congestion, and the opposite side. No significant difference was found in mean CSA-2 reduction rate between the side which was narrow, and the side which was wide before provocation. CONCLUSIONS: Asymmetry of congestive response during bilateral nasal allergen provocation is not dependent on the stage of the nasal cycle preceding the challenge.

Endoscopic transnasal management of inverted papilloma involving frontal sinuses.

Inverted papilloma is a benign locally aggressive tumor of paranasal sinuses which has been traditionally managed with external surgical approaches. Advances in tumor imaging, surgical instrumentation and intraoperative visualization have led to a gradual shift to endonasal attachment-oriented surgery. Involvement of both frontal sinuses by inverted papilloma is rare. There are scant reports in the literature regarding this topic. We present 2 cases of the tumor involving both frontal sinuses removed by median drainage (Draf III procedure) under endoscopic guidance without any additional external approach. The whole cavity of both frontal sinuses was easily inspected at the end of the procedure. No early or late complications were observed. No recurrence was seen in 1-year or 2-year follow-up. Management of frontal sinus inverted papilloma with the endoscopic median drainage approach is feasible and seems to be effective.

[Angifibroma juvenile--evolution of surgical management]. / Ewolucja chirurgicznych metod leczenia wlókniaka mlodzienczego.

INTRODUCTION: Juvenile Angiofibroma has been challenged generations of surgeons. The problem is, not only in specific clinical features of the tumour, but also in difficult surgical approach to anatomical area in which it is located. THE AIM OF THE STUDY: was to analyze development of surgical techniques in treatment of juvenile angiofibroma and potential conditions which influence on therapy results. MATERIAL AND METHOD: The retrospective study that analyzes 47 juvenile angiofibroma cases, which were treated in the Otorhinolaryngology Department of Warsaw Medical University in years 1980­2010. RESULTS: The five surgical approaches were used in the group of patients, filled in this study. The use of midfacial degloving has become increasingly popular, replacing lateral rhinotomy and transpalatal approach, which were commonly used in early nineties of the last century. The infratemporal approach was used in one case of disease with parapharyngeal and infratemporal extension. One of the recent patients was treated, first time in history of the Department, using endoscopic approach. The routine protocol of treatment includes preoperative CT and MRI and angiography with embolization of the main tumour vessels. The gradual, but consequent improvement in therapy results is revealed as reduction of recurrence from 35% to 20%. CONCLUSIONS: In therapy of juvenile angiofibroma become popular surgical techniques, which are not connected with visible scars and which reduce tissue trauma in operated area. Besides mastering surgical skills, the independent condition, which improves therapy results, is using modern diagnostic and therapeutic procedures. They contribute to better assessment of tumour location and extension, and reduction of intraoperative blood loss.