Two-year results: transantral balloon dilation of the ethmoid infundibulum.

BACKGROUND: Multiple prospective and retrospective studies have reported results from balloon-only procedures and hybrid balloon sinus surgeries through intermediate follow-up periods of up to 1 year. Long-term durability results beyond 2 years are limited. METHODS: One-year results from the original study of standalone transantral balloon dilation in patients with computed tomography (CT) evidence of chronic inflammation in the maxillary sinuses alone or maxillary and anterior ethmoid sinuses combined were previously reported. Revision rate, symptom improvement, and productivity improvement were prospectively evaluated after a minimum follow-up of 2 years. RESULTS: Fifty-nine patients (107 maxillary ostia) underwent balloon dilation of the maxillary sinus outflow tract and completed postprocedure follow-up assessment at 27.0 ± 3.6 months. Patient 20-item Sino-Nasal Outcome Test (SNOT-20) score improved from 2.65 ± 0.97 at baseline to 0.79 ± 0.71 at long-term follow-up (p < 0.0001). Improvement in work productivity and activity due to sinus-related health issues for all patients was statistically significant across all survey instrument characteristics (p range, <0.0001 to 0.02). An analysis of the outcomes in a subgroup of patients with maxillary and anterior ethmoid disease (20; 34%) showed similar significant improvement in symptoms (SNOT-20 decrease = -2.1; p < 0.0001). Approximately 92% of all patients reported satisfaction with the balloon procedure. Four (6.8%) patients underwent revision sinus surgery at 11.1 ± 7.3 months after treatment. CONCLUSION: Patients with chronic rhinosinusitis and radiographic evidence of isolated maxillary disease with or without anterior ethmoid disease have reported clinically meaningful and statistically significant improvement in symptoms, productivity, and activity through a minimum of 2 years following standalone balloon dilation.

First clinic experience: patient selection and outcomes for ostial dilation for chronic rhinosinusitis.

BACKGROUND: To report outcomes for subjects undergoing balloon dilation in either the operating room (OR) or the clinic and define criteria to identify suitable candidates for local anesthesia procedures. METHODS: Subjects with medically refractory chronic rhinosinusitis (CRS) underwent de novo surgery via transantral balloon dilation of the maxillary sinus ostium and ethmoid infundibulum. Concomitant nasal or endoscopic sinus surgeries were contraindicated. Technical success, surgical parameters, and long-term outcomes were evaluated through 12-month follow-up. RESULTS: Seventy-one subjects underwent balloon dilation and 94% completed follow-up through 12 months. A total of 132 maxillary ostia were targeted for treatment and 129 were successfully dilated (98%). Almost one-half (33) of the procedures were performed in the OR under local anesthesia with intravenous sedation. Average balloon procedure times for unilateral and bilateral treatment were 28.3 ± 21.1 and 40.2 ± 17.7 minutes, respectively. Thirty-three ostial dilations in 19 subjects were attempted in the clinic. Each ostium was successfully accessed and ballooned under local anesthesia. Patient tolerance was very good with an average self-reported pain level of 2.7 (2 = hurts a little bit) out of 10. Each subject was discharged within 2 hours of the procedure and there was no postoperative bleeding. Symptomatic improvement of the clinic subgroup at 3, 6, and 12 months postprocedure was statistically significant (p ≤ 0.0012) and clinically meaningful and similar in magnitude to improvement seen across all subjects regardless of site of service. CONCLUSION: Transantral balloon dilation can be performed safely in the clinic and operative settings with symptom improvement sustained through 1 year.

Impact of chronic rhinosinusitis on work productivity through one-year follow-up after balloon dilation of the ethmoid infundibulum.

BACKGROUND: Although multiple clinical trials have demonstrated that balloon dilation of sinus ostia in patients diagnosed with chronic rhinosinusitis (CRS) results in sustained symptomatic improvement, less data are available to measure the effects of sinusitis on worker productivity. The objective of our research was to analyze work and activity impairment before and after transantral, endoscopically-guided balloon dilation of the maxillary sinus ostia and ethmoid infundibulum. METHODS: Subjects diagnosed with CRS and computed tomography (CT) evidence of disease in the maxillary sinuses alone, or maxillary and anterior ethmoid sinuses, completed the Work Productivity and Activity Impairment (WPAI) questionnaire and the Work Limitation Questionnaire (WLQ) before treatment and at 3, 6, and 12 months postprocedure. RESULTS: A total of 56 subjects were enrolled and 53 completed the 1-year follow-up. The lost productivity composite score computed from the WLQ improved by 73% (9.0 to 2.4; p < 0.0001) at 1-year follow-up whereas lost productivity at work as measured by the WPAI improved by approximately 76% (38.3 to 9.2; p < 0.0001) 12 months after treatment. CONCLUSION: These results indicate that sinus-related health problems impose a substantial burden on work productivity and physical/mental activity levels. Treatment of CRS by dilating the maxillary sinus ostium and ethmoid infundibulum can significantly improve quality of life (QOL) and work productivity.

A clinical evaluation of bioresorbable staples for mucoperichondrial flap coaptation in septoplasty.

BACKGROUND: During septoplasty surgery, the formation of dead space between the mucosal flaps must be minimized to prevent septal hematoma and promote healing. Historically, this has been achieved by using techniques such as nasal packing or the continuous septal quilting or whip suturing. This study presents the first clinical results using a septal stapling device that uses bioresorbable staples to achieve mucoperichondrial flap coaptation during septoplasty. METHODS: The septal stapler was used in 24 subjects. The primary outcome measure was whether septal coaptation was accomplished 1 week postoperatively. The extent of tissue reaction at the site of staple placement was also evaluated. RESULTS: In all subjects, coaptation with septal staples was successfully accomplished with no septal hematoma formation. At 1 week follow-up, there was either no (79%) or minimal (21%) tissue reaction at the site of staple placement. CONCLUSION: The use of bioresorbable staples appears to be a safe, efficient, and effective alternative to other methods used for mucoperichondrial flap coaptation in septoplasty surgery.

Upper airway. 4: Sarcoidosis of the upper respiratory tract (SURT).

Sarcoidosis of the upper respiratory tract (SURT) includes nasopharyngeal, laryngeal and tracheal disease. Documented SURT occurs in approximately 5% of patients, although upper airway symptoms are more common in patients with sarcoidosis. Wegener granulomatosis may have a similar appearance to SURT, but there are important differences in the manifestations of the disease locally as well as systemically. In some cases, topical treatment is adequate to control SURT. However, many patients with significant sinus or laryngeal disease require long-term systemic treatment. While corticosteroids are often the initial drug of choice, there have been several reports of the effectiveness of cytotoxic agents and anti-tumour necrosis factor antibodies.

Transantral, endoscopically guided balloon dilatation of the ostiomeatal complex for chronic rhinosinusitis under local anesthesia.

BACKGROUND: A multicenter study (BREATHE I - Entellus Medical, Inc.) was performed to assess the safety and outcomes of a new, less invasive system that uses direct endoscopic visualization to facilitate balloon dilation of the maxillary sinus ostia and ethmoid infundibulum. General anesthesia was avoided in most subjects to assess feasibility of performing transantral ostial dilatation in an office setting. METHODS: Subjects with chronic rhinosinusitis of the maxillary sinuses alone or maxillary and anterior ethmoid sinuses underwent baseline evaluation including CT imaging and symptom assessment using the Sino-Nasal Outcome Test (SNOT 20). Subjects underwent transantral balloon dilation and follow-up evaluation at 1 week, 3 months, and 6 months post-procedure. RESULTS: Thirty subjects were treated at three centers. Fifty-five of 58 maxillary ostia were successfully treated for a procedural completion rate of 94.8%. Ninety-seven percent of the procedures were completed under local anesthesia with or without minimal intravenous sedation. There were no device-related serious adverse events or unanticipated adverse device effects. The mean overall SNOT 20 score at baseline was 2.9 +/- 1.0. Mean overall SNOT 20 scores at 1-week, 3-month, and 6-month follow-up were 0.8 +/- 0.8, 0.7 +/- 0.8, and 0.8 +/- 0.9 respectively. Patency at 3-months as confirmed by CT imaging was 95.8%. CONCLUSION: These results indicate that transantral balloon dilation of the ostiomeatal complex under local anesthesia appears to be a safe technique for managing isolated maxillary or maxillary and anterior ethmoid sinusitis and can potentially be performed safely in an office setting.

Surgical management of lesions of the sphenoid lateral recess.

BACKGROUND: Pneumatization of the sphenoid sinus occasionally includes an extensive lateral recess creating an area beneath the temporal lobe that is relatively inaccessible to surgical intervention. Pathology in this anatomic location presents special surgical and therapeutic challenges. Recently, several authors have described the endoscopic transpterygopalatine fossa approach to this anatomic region. This approach is associated with minimal morbidity while providing direct endoscopic surgical access for managing a variety of disease processes in this region. METHODS: This study presents eight cases requiring this approach or a modification of this approach. Six patients presented with temporal lobe meningoencephaloceles with cerebrospinal fluid rhinorrhea. Each case was managed successfully through this surgical approach. RESULTS: One patient experienced transient postoperative palatal anesthesia due to injury to the greater palatine nerve and another complained of ipsilateral dry eye postoperatively. Two other patients had neoplasms (inverting papilloma and chondrosarcoma), which were successfully addressed through this technique. There were no postoperative complications in these patients. CONCLUSION: We have previously described the relationships of neural and vascular structures in this anatomic region. This article will review these relationships as they pertain to this surgical approach and will discuss the indications, techniques, and surgical outcomes in this series of patients. This approach is a valuable addition to the endoscopic armamentarium of the experienced endoscopic surgeon.

Granulomatous diseases and chronic rhinosinusitis.

Chronic rhinosinusitis often fails to respond to standard medical or surgical treatment. In some of these cases, the underlying disease may be a chronic granulomatous process that requires aggressive topical, local, and in some instances, systemic therapy. Diseases that can present in this manner include autoimmune vasculitis, sarcoidosis, indolent infections, neoplastic processes, and various other miscellaneous conditions. This article reviews the typical presentations for some of these unusual conditions and discusses the appropriate evaluations that will lead to clinical identification and effective medical management.

Sinusitis in HIV: microbiology and therapy.

Rhinosinusitis in the HIV-infected population is an increasingly common finding as HIV infection has transitioned toward becoming a chronic medical condition. In this patient population, rhinosinusitis may be challenging to diagnose and treat effectively. However, adequate diagnostic tools are available, microbial identity can be reasonably anticipated based on the CD4 count, and effective management strategies can be implemented. In this article, we discuss the diagnostic and therapeutic options for HIV-infected patients with rhinosinusitis.

Use of a powered shaver to remove multiple oral cavity papillomas.

We report a previously undescribed method of removing multiple oral papillomas, which we performed on 5 men with human immunodeficiency virus (HIV) infection. Patients were brought to the operating room and placed under general anesthesia. In addition, 1% lidocaine with 1:100,000 epinephrine was injected under and around the lesions. We then removed the lesions with a Tricut laryngeal blade attached to a handheld powered shaver Postoperatively, patients were sent home on clindamycin, a pain medication, and Peridex. At the 1-week follow-up, patients reported only minimal pain, and their wounds were well healed. We observed no adverse events associated with the shaving procedure. Our method expedites the process of removing multiple oral cavity papillomas while reducing the morbidity generally associated with other procedures.

Sinusitis in HIV: Microbiology and Therapy.

Rhinosinusitis in the HIV-infected population is an increasingly common finding as HIV infection has transitioned toward becoming a chronic medical condition. In this patient population, rhinosinusitis may be challenging to diagnose and effectively treat. However, adequate diagnostic tools are available, microbial identity can be reasonably anticipated based on the CD4 count, and effective management strategies can be implemented. This article discusses the diagnostic and therapeutic options for HIV-infected patients with rhinosinusitis.

An endoscopic study of the greater palatine nerve.

BACKGROUND: Using an endoscopic approach, lateral sphenoid air cells and terminal branches of the internal maxillary artery often can be accessed through the pterygomaxillary fossa: however, injury to the greater palatine nerve (GPN) can occur if the anatomy of this region is not understood clearly. This study was undertaken to define the pathway of the GPN and to identify landmarks useful in preventing its injury. METHODS: Six cadaveric heads were used to endoscopically dissect and examine 11 pterygomaxillary fossae. An additional latex-injected cadaveric head was sectioned coronally and dissected bilaterally. The relationships between the vascular, neurological and bony structures and foramena were noted and described. RESULTS: All specimens studied maintained consistent relationships. The sphenopalatine and posterior nasal arteries cross nearly perpendicular and just superficial to the GPN. The GPN traveled anteriorly and inferiorly to reach the greater palatine foramen. The lateral wall of the canal ranged from a thin bony covering to complete dehiscence and was thinnest as it crossed the inferior turbinate and approached the foramen. The foramen rotundum was located lateral and superior to the sphenopalatine foramen near the roof of the maxillary sinus. CONCLUSION: When surgically approaching the pterygomaxillary fossa, injury to the GPN is avoidable by thorough knowledge of anatomy and awareness of the described landmarks.

Special features topic: the effects of limited work hours on surgical training in otolaryngology-head and neck surgery.

PURPOSE OF REVIEW: This paper reviews the historic events that culminated in the development of duty hour regulations, and then discusses many of the problems being encountered as the regulations are implemented. RECENT FINDINGS: On July 3, 2003, the Accreditation Council for Graduate Medical Education (ACGME) instituted duty hour requirements for residency training programs in the United States. Although these regulations should have come as no surprise to graduate medical education programs, many were nevertheless unprepared for their implementation. In comparison to duty hour restrictions currently in place in European countries, those being implemented in this country are much more lenient. Both the fiscal and the educational impact of these requirements on graduate medical education are substantial. Recent accreditation actions taken against a training program at Johns Hopkins University clearly demonstrates that the ACGME is prepared to strictly enforce these standards. SUMMARY: The impact of the new duty-hour requirements on residency training and education will be a matter of great interest as they are implemented throughout the graduate education system in the United States.

Endoscopic management of anterior skull base encephaloceles.

Encephaloceles are relatively rare phenomena produced by the protrusion of brain and dura through an anterior skull base defect. Although they can occur as congenital defects, encephaloceles can also present after trauma. The diagnosis is usually made with nasal endoscopy and imaging studies. This report reviews our recent experience repairing 5 encephaloceles in 4 patients. The diagnostic approach and the technical aspects of surgical management are discussed. Although encephaloceles are a rarity, this diagnosis should be considered as part of the differential diagnosis in evaluating a patient with a unilateral polypoid nasal mass, particularly in the setting of recurrent meningitis or cerebrospinal fluid rhinorrhea.

Ear, nose, and throat manifestations of sarcoidosis.

Sarcoidosis rarely affects the head and neck and represents a diagnostic challenge to the otolaryngologist. The signs and symptoms of sarcoidosis in this area are not specific and can mimic much more common disorders. Biopsy is usually necessary to make the diagnosis. Appropriate evaluations and referrals should be made once there is suspicion of sarcoidosis. Steroids remain the mainstay of the therapeutic options; however, newer agents are being used more frequently. Long-term treatment and follow-up are necessary, because the disease tends to progress and to respond unpredictably to treatment.