[Transnasal endoscopic anatomy and approaches to the cavernous sinus].

OBJECTIVE: The goal of the current study is to describe the transnasal endoscopic anatomy of the cavernous sinus and to provide the surgical approaches to this area. METHODS: Six silicon-injected adult cadaveric heads (12 sides) were dissected through endoscopic endonasal approach. The cavernous sinus and adjacent structures were exposed; detailed anatomies were demonstrated. High-quality pictures were produced. RESULTS: The cavernous sinus had four walls, namely medial, lateral, posterior and superior walls. Five venous spaces within the sinus were identified by their relation to the carotid artery; those were the medial, lateral, posterosuperior, posteroinferior and anterolateral compartments. Three branches arising from the cavernous segment of internal carotid artery from proximal to distal were meningohypophyseal trunk, inferolateral trunk and McConnell capsular artery. Cavernous sinuses communicated each other by intercavernous sinuses, as well as basilar sinus in middle line, and connected with superior and inferior petrosal sinuses. The third and fourth nerves coursed in superior part of the lateral wall of the cavernous sinus; Meckel's cave located in the posteroinferior part of the lateral wall of the cavernous sinus; V1 sloped to the superior orbital fissure along the lateral wall; the sixth nerve entered the posteroinferior compartment then passed through the internal carotid artery and reached to superior orbital fissure. The approaches to the cavernous sinus included trans-sphenoid-sellar-medial cavernous sinus (medial to the internal carotid artery) and trans-ethmoid-pterygoid-sphenoid-lateral cavernous sinus (lateral to the internal carotid artery). Trans-sphenoid-sellar-medial cavernous sinus approach was able to expose medial compartment and posterosuperior compartment and part of posteroinferior compartment. Trans-ethmoid-pterygoid-sphenoid-lateral cavernous sinus approach was able to expose anteroinferior compartment, lateral cavernous sinus and cranial nerves in lateral wall. CONCLUSION: An understanding of the complex relationships of the cavernous segment of internal carotid artery and cranial nerves in cavernous sinus is paramount for surgically dealing with the disease involved cavernous sinus and adjacent region.

[Relationship between the tinnitus frequency and the effects of medication and the prognosis in patients with chronic subjective tinnitus].

OBJECTIVE: To investigate the influence of tinnitus frequency on medication and prognosis in patients with chronic subjective tinnitus. METHODS: Seventy-two patients (Ninety-three ears) diagnosed as chronic subjective tinnitus were studied from October 2010 to March 2011. All cases were divided into low frequency(twenty-three ears), medium frequency(fourteen ears) and high frequency (fifty-six ears) according to tinnitus matching test. All cases were treated with microcirculation promotion and steroid therapy (5% glucose 250 ml + ginkgo biloba extract 87.5 mg + dexamethasone 10 mg intravenous drip). Curative effect was evaluated and the factors of prognosis were analyzed after three weeks. RESULTS: After medication, results were acquired as follows: recovery in 0 ear (0%), excellent in 0 ear (0%), effective in 18 ears (19.4%), invalid in 75 ear (80.6%). The effective percentage was 39.1%, 35.7% and 7.1%, respectively. There was significant difference between these groups, but no significant difference between low frequency and medium frequency. Logistic regression analysis showed that the difference of frequency was significant prognostic factors for medication. CONCLUSIONS: Microcirculation promotion and steroid therapy had a poor treatment effect in patients with chronic subjective tinnitus. The prognosis of chronic low-medium frequency tinnitus was better than chronic high frequency tinnitus. The difference of frequency retained significant influence on effects and prognosis of medication.

[Expression of metallothionein 2 in middle ear cholesteatoma and its correlation with interleukin 1α and interleukin 6].

OBJECTIVE: To detect the expression and distribution of metallothionein 2 (MT-2) in middle ear cholesteatoma, and to explore the relationship of MT-2 with interleukin 1α (IL-1α) and interleukin 6 (IL-6), and well as to explore the role of MT-2 in the pathogenetic mechanism of middle ear cholesteatoma. METHODS: Using the immunohistochemistry and reverse transcription polymerase chain reaction to examine the expressions of MT-2, IL-1α and IL-6 protein and MT-2 mRNA in twenty-five middle ears' cholesteatoma and seven normal external ears' canal skin. The influence of cholesteatoma debris on the MT-2 mRNA and protein of HaCaT cell were further analyzed. RESULTS: According to immunohistochemistry research, the expressions of MT-2, IL-1α and IL-6 were extremely higher in middle ear cholesteatoma than those in normal external ears' canal skin (P < 0.05). The result of RT-PCR showed that there was significant difference between the expression of MT-2 mRNA of and middle ear cholesteatoma than those in normal external ear canal skin (t = 15.38, P < 0.05). There was a positive correlation between the expression of MT-2 and that of IL-1α (r = 0.856, P < 0.05). There was also positive correlation between the expression of MT-2 and that of IL-6 (r = 0.714, P < 0.05). MT-2 mRNA and protein of HaCaT cell significantly increased when exposed to cholesteatoma debris in a dose dependent manner. CONCLUSIONS: MT-2, IL-1α and IL-6 may play an important role in the pathogenetic process of middle ear cholesteatoma. Cholesteatoma debris may involve in the proliferation of middle ear cholesteatoma by activation of MT-2.

[Clinical and magnetic resonance imaging characteristics of isolated congenital anosmia].

OBJECTIVE: To report a series of patients with isolated congenital anosmia and summarize their clinical and magnetic resonance imaging (MRI) characteristics. METHODS: Twenty patients with isolated congenital anosmia were reviewed retrospectively. A thorough medical and chemosensory history, physical examination, nasal endoscopy, T&T olfactory testing, olfactory event-related potentials, sinonasal computed tomography scan and magnetic resonance image of olfactory pathway were performed in all patients. RESULTS: Neither ENT physical examination nor nasal endoscopy was remarkable. Subjective olfactory testing indicated all of them were of anosmia. No olfactory event-related potentials to maximal stimulus were obtained. Computed tomography scan was normal. MRI revealed the absence of olfactory bulbs and tracts in all cases. And hypoplasia or aplasia of olfactory sulcus was found in all cases. All the patients had normal sex hormone level. CONCLUSION: The diagnosis of isolated congenital anosmia is established on chief complaints, physical examination, olfactory testing and olfactory imaging. MRI of olfactory pathway is indispensable.

[Posttraumatic anosmia: olfactory event related potentials and MRI evaluation].

OBJECTIVE: Using olfactory event related potentials (OERP) and magnetic resonance to evaluate olfactory function in patients with posttraumatic anosmia. METHODS: Twenty four patients with posttraumatic anosmia were reviewed retrospectively. A thorough medical history, physical examination, nasal endoscopy, T&T olfactory testing, olfactory event-related potentials, brain computed tomography scan and magnetic resonance image of olfactory pathway were performed in all patients. RESULTS: Subjective olfactory testing indicated 20 of 24 patients were birhinal anosmia, 2 with right nostril anosmia and left impairment, 2 with left anosmia and right normal. No OERP were obtained in 24 (20 were birhinal, 4 was monorhinal), except 4 cases with single nostril. Magnetic resonance imaging revealed the injures to the olfactory bulbs (100%), rectus gyrus (91.7%), orbital gyrus (67%), olfactory tracts (8%) and temporal lobes (8%). CONCLUSIONS: OERP can objectively evaluate posttraumatic olfactory function, and magnetic resonance of olfactory pathway can precisely identify the location and extent of injures.

[Diagnostic value for detection of aspergillus ribosomal RNA in fungal rhinosinusitis with hybridization in situ].

OBJECTIVE: To develop a reliable, rapid assay for detecting pathogenic aspergillus species in fungal sinusitis. METHODS: Thirty-seven formalin-fixed and paraffin-embedded surgical tissue specimens from patients with fungal sinusitis were used in the present study. The aspergillus specific oligonucleotide probe was designed, commercially synthesized, and digoxigenin-labeled. Twenty-three-base oligonucleotides was selected that was complementary to 18S ribosomal RNA sequences (18S-1 probe) for detecting medically important aspergillus species. RESULTS: In situ hybridization for aspergillus rRNA was positive in 28 cases with the 18S-1 probe. Compared with HE (21) and methenamine-silver stain (23). CONCLUSION: In situ hybridization provides rapid and accurate identification for fungal organism in tissues, and may be useful if cultures are negative or have not performed.

[Management of intractable epistaxis and bleeding points localization].

OBJECTIVE: To investigate the common nasal bleeding points and the management of intractable epistaxis. METHODS: The bleeding points and its correlation with age distribution, surgical techniques as well as its effects were studied retrospectively in 92 patients, in whom the bleeding points were not found by routine nasal endoscopy and the hemorrhage was not controlled with standard nasal packing. RESULTS: The bleeding points were found in the following different sites: superior wall of inferior nasal meatus (56.5%, 52/92), olfactory cleft of nasal septum (27.2%, 25/92), posterosuperior wall of middle nasal meatus (8.7%, 8/92) and uncertain (7.6%, 7/92). The results showed that the bleeding points had correlation with age. Epistaxis was well controlled by electrocoagulation in 83 cases, gelfoam packing in 8 cases, and transcatheter maxillary artery embolization in 1 case. There were no complications during a followed-up for 1 - 3 months after management. Among the 92 cases, the numbers of treatment needed to stop bleeding were 82 cases (89.1%) after 1 time of treatment, 9 cases (9.8%) after 2 times and in one case (1.1%) after 4 times. CONCLUSIONS: Endoscopy combined with displacement of the middle and inferior turbinate gives good visualization and direct management of the deeply-sited bleeding points, which were difficult in localization. The combined method provides an effective and safe way to control intractable epistaxis.

[Image-guided endoscopic transsphenoidal removal of pituitary adenoma].

OBJECTIVE: To assess the role of neuronavigation in assisting endoscopic transsphenoidal surgery for pituitary adenomas. METHODS: Ten endoscopic endonasal transsphenoidal reoperations for pituitary adenomas were selected. Clinical records were reviewed retrospectively. Five of 10 patients had gigantic adenoma, 3 microadenoma, 2 large adenoma. RESULTS: The mean setup time was 5 minutes, and the operative time was 50 minutes in image-guided procedures. In all cases, the system worked well without malfunction. Continuous information regarding instrument location and trajectory was provided to the surgeon. Measurements of intraoperative accuracy in the axial, coronal, and.sagittal planes indicated a mean verified system error of 1.5 mm. for pituitary adenomas. After operation, the symptoms relieved in all patients. CONCLUSIONS: Neuronavigation can be applied during endonasal transsphenoidal endoscopic surgery and requires a minimal amount of time. It makes reoperation easier, faster, and safer.

[Immunohistochemical diagnosis of fungus ball in paranasal sinuses].

OBJECTIVE: To study the pathogens of fungus balls in paranasal sinuses and establish an immunohistochemical test by which the main opportunistic fungi could be identified. METHODS: Twenty-five patients with fungal balls were treated by surgical removal of the fungus ball in the infected sinuses. The pathogenic fungi on the specimens were identified by means of routine PAS and immunohistochemical staining methods, and the sensitivity of the two methods were compared. RESULTS: The most commonly infected sinus was the maxillary sinus, followed by sphenoid sinus. Pathogens of fungal balls were found to be aspergillus (92%, 23/25) and candida 2 cases (8%). Aspergillus and candida albicans in infected sinuses could be specifically identified by immunostainning. There was no statistically significant differences of sensitivity between immunostainning and PAS stain. CONCLUSIONS: The main pathogen of the fungus ball was aspergillus. Immunostainning was a rapid and reliable method to identify fungi in infected tissues of paranasal sinuses. It should be widely used in the diagnosis of fungal sinusitis.