Expanding the limits of endoscopic intraorbital tumor resection using 3-dimensional reconstruction / Expandindo os limites da ressecção endoscópica de tumor intraorbital utilizando reconstrução tridimensional

Abstract Introduction: Endoscopic orbital surgery is a nascent field and new tools are required to assist with surgical planning and to ascertain the limits of the tumor resectability. Objective: We purpose to utilize three-dimensional radiographic reconstruction to define the theoretical lateral limit of endoscopic resectability of primary orbital tumors and to apply these boundary conditions to surgical cases. Methods: A three-dimensional orbital model was rendered in 4 representative patients presenting with primary orbital tumors using OsiriX open source imaging software. A 2-Dimensional plane was propagated between the contralateral nare and a line tangential to the long axis of the optic nerve reflecting the trajectory of a trans-septal approach. Any tumor volume falling medial to the optic nerve and/or within the space inferior to this plane of resectability was considered theoretically resectable regardless of how far it extended lateral to the optic nerve as nerve retraction would be unnecessary. Actual tumor volumes were then superimposed over this plan and correlated with surgical outcomes. Results: Among the 4 lesions analyzed, two were fully medial to the optic nerve, one extended lateral to the optic nerve but remained inferior to the plane of resectability, and one extended both lateral to the optic nerve and superior to the plane of resectability. As predicted by the three-dimensional modeling, a complete resection was achieved in all lesions except one that transgressed the plane of resectability. No new diplopia or vision loss was observed in any patient. Conclusion: Three-dimensional reconstruction enhances preoperative planning for endoscopic orbital surgery. Tumors that extend lateral to the optic nerve may still be candidates for a purely endoscopic resection as long as they do not extend above the plane of resectability described herein.

Resumo Introdução: A cirurgia orbital endoscópica é um campo emergente e são necessárias novas ferramentas para auxiliar no planejamento cirúrgico e determinar os limites da ressecabilidade tumoral. Objetivo: Usar a reconstrução radiográfica tridimensional para definir o limite lateral teórico de ressecabilidade endoscópica de tumores orbitais primários e aplicar essas condições de limites a casos cirúrgicos. Método: Um modelo orbital tridimensional foi aplicado a quatro pacientes representativos com tumores orbitais primários utilizando o software de imagem de fonte aberta OsiriX. Um plano bidimensional foi propagado entre a narina contralateral e uma linha tangencial ao eixo longo do nervo óptico que reflete a trajetória de uma abordagem transeptal. Qualquer volume de tumor situado medialmente ao nervo óptico e/ou dentro do espaço inferior a esse plano de ressecabilidade foi teoricamente considerado ressecável, independentemente de quão longe ele se estendia até o nervo óptico, pois a retração do nervo seria desnecessária. Os volumes reais do tumor foram então sobrepostos sobre esse plano e correlacionados com os resultados cirúrgicos. Resultados: Entre as quatro lesões analisadas, duas eram totalmente mediais ao nervo óptico, uma se estendia lateralmente ao nervo óptico, mas permaneceu inferior ao plano de ressecabilidade, e uma se estendia lateralmente ao nervo óptico e superior ao plano de ressecabilidade. Conforme previsto pelo modelo tridimensional, uma ressecção completa foi obtida em todas as lesões, exceto uma, que transgrediu o plano de ressecabilidade. Nenhuma nova diplopia ou perda de visão foi observada em qualquer paciente. Conclusão: A reconstrução tridimensional melhora o planejamento pré-operatório para a cirurgia orbital endoscópica. Os tumores que se estendem lateralmente ao nervo óptico podem ainda ser candidatos à ressecção puramente endoscópica, desde que não se estendam além do plano de ressecabilidade aqui descrito.

Improvement in nasal obstruction and quality of life after septorhinoplasty and turbinate surgery.

OBJECTIVES: To evaluate the long-term impact of functional septorhinoplasty (SRP) with and without inferior turbinate reduction (ITR) on disease-specific symptom severity and general health-related quality of life (QOL). STUDY DESIGN: Prospective cohort study at a tertiary referral center. METHODS: Patients undergoing functional SRP with and without ITR were administered the Nasal Obstruction Symptom Evaluation (NOSE) scale to assess severity of nasal obstruction and the EuroQol-5 Dimension Questionnaire Visual Analog Scale (EQ-5D VAS) to assess general health-related QOL preoperatively and at 2, 4, 6, 12, 24, and 36 months postoperatively. Patient demographics, surgical technique, symptom severity, and QOL outcomes were analyzed. RESULTS: A total of 567 patients were included, with 391 patients undergoing functional SRP alone (54.0% female; mean age 36.0 years [standard deviation (SD):16.2]) and 176 patients undergoing functional SRP with ITR (50.0% female; mean age 35.6 years [SD:13.6]). There was a significant decrease in NOSE and increase in EQ-5D VAS scores in both groups through at least 24 months postoperatively. Change in NOSE scores was negatively correlated with change in EQ-5D VAS (r = -0.38, P < 0.01). Compared to patients undergoing SRP, patients also undergoing ITR had a statistically but nonclinically significant improvement in NOSE, with similar trends for EQ-5D VAS that were not significant. CONCLUSION: SRP results in a sustained, long-term improvement in nasal obstruction based on disease-specific and general health-related QOL measures, with incremental improvement in outcomes with addition of ITR. This study provides the foundation for defining health outcomes and the health utility value of surgical interventions that address nasal obstruction. LEVEL OF EVIDENCE: 2c Laryngoscope, 129:1554-1560, 2019.

Expanding the limits of endoscopic intraorbital tumor resection using 3-dimensional reconstruction.

INTRODUCTION: Endoscopic orbital surgery is a nascent field and new tools are required to assist with surgical planning and to ascertain the limits of the tumor resectability. OBJECTIVE: We purpose to utilize three-dimensional radiographic reconstruction to define the theoretical lateral limit of endoscopic resectability of primary orbital tumors and to apply these boundary conditions to surgical cases. METHODS: A three-dimensional orbital model was rendered in 4 representative patients presenting with primary orbital tumors using OsiriX open source imaging software. A 2-Dimensional plane was propagated between the contralateral nare and a line tangential to the long axis of the optic nerve reflecting the trajectory of a trans-septal approach. Any tumor volume falling medial to the optic nerve and/or within the space inferior to this plane of resectability was considered theoretically resectable regardless of how far it extended lateral to the optic nerve as nerve retraction would be unnecessary. Actual tumor volumes were then superimposed over this plan and correlated with surgical outcomes. RESULTS: Among the 4 lesions analyzed, two were fully medial to the optic nerve, one extended lateral to the optic nerve but remained inferior to the plane of resectability, and one extended both lateral to the optic nerve and superior to the plane of resectability. As predicted by the three-dimensional modeling, a complete resection was achieved in all lesions except one that transgressed the plane of resectability. No new diplopia or vision loss was observed in any patient. CONCLUSION: Three-dimensional reconstruction enhances preoperative planning for endoscopic orbital surgery. Tumors that extend lateral to the optic nerve may still be candidates for a purely endoscopic resection as long as they do not extend above the plane of resectability described herein.

SNOT-22 score patterns strongly negatively predict chronic rhinosinusitis in patients with headache.

BACKGROUND: Differentiating the non-sinogenic headache from chronic rhinosinusitis (CRS) remains a significant clinical challenge due to the extensive overlap in symptoms. The objective of this study was to evaluate the 22-item Sino-Nasal Outcome Test (SNOT-22) score patterns in patients with confirmed non-sinogenic headache in order to develop negative predictors of CRS. METHODS: Institutional Review Board (IRB)-approved, retrospective review of patients diagnosed with CRS or non-sinogenic headache defined as patients with a chief complaint of headache, facial pain, and facial pressure in the absence of both endoscopic and computed tomography (CT) evidence of inflammation. The optimal cutoff points of potential predictors of non-sinogenic headache by SNOT-22 score were quantified by receiver operating characteristic (ROC) curve. The negative predictive values (NPVs) for CRS were calculated in a discovery population and then validated in an independent population. RESULTS: A total of 724 (164 non-sinogenic headache and 560 CRS) and 412 (88 non-sinogenic headache and 324 CRS) patients were recruited in the discovery and validation populations, respectively. Domain 3 (Ear/facial) and domain 4 (Psychological dysfunction) were significantly higher in patients with non-sinogenic headache as compared with CRS while domain 1 (Rhinologic) and domain 2 (Extranasal rhinologic) were significantly lower. The top 4 predictors of non-sinogenic headache were the domain 3 (Ear/facial)/domain 1 (Rhinologic) ratio, item 12, domain 3 (Ear/facial), and (item 12 + item 10)/(item 4 + item 5) ratio, with areas under the ROC curve (AUCs) ranging from 0.637 to 0.720 by ROC curve. A domain 3 (Ear/facial)/domain 1 (Rhinologic) ratio over 0.66 performed as the best negative predictor of CRS with the highest NPVs of 0.880 and 0.889 in the discovery and validation populations, respectively. CONCLUSION: Patients with non-sinogenic headache have distinct SNOT-22 score patterns compared with patients with CRS. A domain 3 (Ear/facial)/domain 1 (Rhinologic) ratio greater than 0.66 is a strong negative predictor of CRS, which can be used to aid in patient counseling and potentially limit the use of unnecessary sinonasal therapeutics.

General antibiotic exposure is associated with increased risk of developing chronic rhinosinusitis.

OBJECTIVE: Antibiotic use and chronic rhinosinusitis (CRS) have been independently associated with microbiome diversity depletion and opportunistic infections. This study was undertaken to investigate whether antibiotic use may be an unrecognized risk factor for developing CRS. STUDY DESIGN: Case-control study of 1,162 patients referred to a tertiary sinus center for a range of sinonasal disorders. METHODS: Patients diagnosed with CRS according to established consensus criteria (n = 410) were assigned to the case group (273 without nasal polyps [CRSsNP], 137 with nasal polyps [CRSwNP]). Patients with all other diagnoses (n = 752) were assigned to the control group. Chronic rhinosinusitis disease severity was determined using a validated quality of life (QOL) instrument. The class, diagnosis, and timing of previous nonsinusitis-related antibiotic exposures were recorded. Results were validated using a randomized administrative data review of 452 (38.9%) of patient charts. The odds ratio of developing CRS following antibiotic exposure were calculated, as well as the impact of antibiotic use on the subsequent QOL. RESULTS: Antibiotic use significantly increased the odds of developing CRSsNP (odds ratio: 2.21, 95% confidence interval, 1.66-2.93, P < 0.0001) as compared to nonusers. Antibiotic exposure was significantly associated with worse CRS QOL scores (P = 0.0009) over at least the subsequent 2 years. These findings were confirmed by the administrative data review. CONCLUSION: Use of antibiotics more than doubles the odds of developing CRSsNP and is associated with a worse QOL for at least 2 years following exposure. These findings expose an unrecognized and concerning consequence of general antibiotic use. LEVEL OF EVIDENCE: 3b. Laryngoscope, 2016 127:296-302, 2017.

Lobular capillary hemangioma formation: An unusual complication of submucous resection with power instrumentation of the inferior turbinate.

Submucous resection with powered instrumentation (SRPI) is an effective surgical method to achieve inferior turbinate (IT) reduction with minimal morbidity. We describe a series of two cases of capillary hemangioma (pyogenic granuloma) that developed in the posterior third of the IT as a late complication after SRPI.

Volumetric analysis of chronic maxillary atelectasis.

BACKGROUND: The relationship between orbit and maxillary sinus volumes in patients with chronic maxillary atelectasis (CMA), commonly known as silent sinus syndrome if enophthalmos is present, is poorly understood. METHODS: A retrospective review of 22 patients who underwent endoscopic sinus surgery (ESS) for CMA from 2005 to 2013 was performed. Computed tomography (CT) images were analyzed using OsiriX 5.8.2 software for volumetric analysis of the orbit and maxillary sinus at presentation and after surgical treatment with ESS. RESULTS: Pretreatment mean orbit volumes on the diseased side (DS) and the contralateral side (CS) were 29.22 and 26.50 mL, respectively (p < 0.001); mean sinus volumes on the DS and CS were 8.51 and 17.20 mL, respectively (p < 0.001); and pretreatment mean midorbit heights (MOHs) on the DS and CS were 3.39 cm and 3.07 cm, respectively (p < 0.001). The percent decrease in sinus volume on the DS compared to that on the CS did not correlate significantly with the percent orbit-volume increase. Enophthalmos was present in nine (41%) patients, and diplopia was present in three (14%) patients. The measured degree of increased orbit volume and decreased sinus volume secondary to CMA did not significantly predict the presence of enophthalmos at presentation. Seven patients underwent sinus CT more than 6 months after ESS. In these patients, orbit volume on the DS decreased from 29.67 to 27.52 mL (p = 0.005), and sinus volume on the DS increased from 9.78 to 11.84 mL (p = 0.08). CONCLUSIONS: Volumetric analysis is a powerful and novel method for objectively demonstrating the degree of orbit expansion and maxillary sinus contraction seen with CMA. Spontaneous maxillary sinus expansion and a decrease in orbit volume can occur after ESS, but post-ESS volumes do not return to the normal volume of the CS.

Profibrotic transforming growth factor beta 1 and activin A are increased in nasal polyp tissue and induced in nasal polyp epithelium by cigarette smoke and Toll-like receptor 3 ligation.

BACKGROUND: The mechanism of airway remodeling in chronic rhinosinusitis with nasal polyposis (CRSwNP) remains unknown. We wished to determine whether profibrotic transforming growth factor beta 1 (TGF-ß1) and activin A and their downstream signaling proteins are increased in CRSwNP and if they are regulated in epithelial cells by noxious or inflammatory stimuli. METHODS: Frozen tissue from CRSwNP patients, healthy control (HC) middle turbinates, and sinus tissue from CRS without NP (CRSsNP) patients were immunostained for TGF-ß1, activin A, and downstream signaling proteins. Primary nasal epithelial cells (PNECs) from HCs and CRSwNP patients were cultured in media, cigarette smoke extract (CSE), or double-stranded RNA (dsRNA) (a ligand for Toll-like receptor-3) and examined for inflammatory and profibrotic genes using real-time polymerase chain reaction (PCR). RESULTS: CRSwNP patients showed increased TGF-ß1 and activin A in the stroma, increased TGF-ß1 signaling (phosphorylated Smad2/3) in the stroma and epithelium, and increased Smad3-dependent Snail1 in the stroma. Immunostaining for TGF-ß1, pSmad2/3, and Snail1 in CRSwNP patients was highly correlated. Immunostaining for pSmad2/3 and Snail1 was similar in CRSwNP and CRSsNP patients. Compared to HCs, PNECs from CRSwNP patients were more responsive to CSE and dsRNA in terms of TGF-ß1 and activin A and more strongly induced by dsRNA in terms of chemokines. CONCLUSION: Increased TGF-ß1 and activin A and increased downstream TGF-ß1 signaling is present in CRSwNP patients, primarily in the stroma. This may contribute to features of airway remodeling previously described. PNECs from CRSwNP patients are induced to produce TGF-ß1 and activin A by CSE and dsRNA, suggesting that cigarette smoke and viral infection might also contribute to airway remodeling.

Radiographic evaluation of nasal septal deviation from computed tomography correlates poorly with physical exam findings.

BACKGROUND: Performance of septoplasty is dependent on objective evidence of nasal septal deviation. Although physical examination including anterior rhinoscopy and endoscopic examination is the gold standard for evaluation of septal deviation, third-party payors' reviews of septoplasty claims are often made on computed tomography (CT) findings. However, the correlation between radiographic evaluation of septal deviation with physical examination findings is unknown. METHODS: Retrospective, blinded, independent evaluation of septal deviation in 39 consecutive patients from physical examination, including anterior rhinoscopy and endoscopic examination, by an otolaryngologist and radiographic evaluation of sinus CT scan by a neuroradiologist. Four distinct septal locations (nasal valve, cartilaginous, inferior/maxillary crest and osseous septum) were evaluated on a 4-point scale representing (1) 0% to 25%, (2) >25% to 50%, (3) >50% to 75%, and (4) >75% obstruction. Correlation between physical examination and radiographic evaluations was made by Pearson's correlation and quantitative agreement assessed by Krippendorf's alpha. RESULTS: Statistically significant correlation was detected between physical examination including nasal endoscopy and radiographic assessment of septal deviation only at the osseous septum (p = 0.007, r = 0.425) with low quantitative agreement (α = 0.290). No significant correlation was detected at the cartilaginous septum (p = 0.286, r = 0.175), inferior septum (p = 0.117, r = 0.255), or nasal valve (p = 0.174, r = 0.222). Quantitative agreement at the nasal valve suggested a bias in CT to underestimate physical exam findings (α = -0.490). CONCLUSION: CT is a poor substitute for physical examination, the gold standard, in assessment of septal deviation. Clinical decisions about pursuit of septoplasty or third-party payors' decisions to approve septoplasty should not be made on radiographic evidence.

The impact of a patient's age on the clinical presentation of inflammatory paranasal sinus disease.

OBJECTIVE: To determine the change in the clinical presentation of inflammatory paranasal sinus disease as a function of a patient's age. STUDY DESIGN AND METHODS: This is a prospective study of 514 adult patients who presented with inflammatory paranasal sinus disease. The patients were divided into three age groups: group 1 (age: 18-39 years; n=203), group 2 (age: 40-59 years; n=213) and group 3 (age greater than 60 years; n=98). The following data were collected: presenting symptoms, co-morbidities, nasal endoscopy and CT findings, diagnosis, and the outcome of endoscopic sinus surgery (ESS). Statistical analysis was performed using chi-square test, with statistical significance set at p<0.05. RESULTS: Among the presenting symptoms, facial pain and rhinorrhea were most common in group 1 (p<0.05), while dysosmia was most common in group 3 (p<0.05). Environmental allergy, but not asthma, was more prevalent in groups 1 and 2 (p<0.05). Anatomic abnormalities that obstructed the ostiomeatal unit (OMU) were more common in groups 1 and 2 (p<0.05). Chronic rhinosinusitis (CRS) without polyposis was the most common diagnosis in group 1 and CRS with polyposis was the most common diagnosis in groups 2 and 3 (p<0.05). Patients in group 1 reported higher rate of improvement in olfactory function while patients in group 3 reported higher rate of improvement in rhinorrhea following ESS (p<0.05). CONCLUSIONS: Patients in the 18-39-year age group and diagnosed with CRS are more likely to present with facial pain, suffer from environmental allergy, have anatomic abnormalities in the OMU region, and report improvement in their olfaction following ESS. Patients who are 60 years or older are more likely to present with dysosmia, be diagnosed with CRS with nasal polyposis, and report improvement in rhinorrhea following surgery.

Diagnostic characteristics of sinonasal organizing hematomas: avoiding misdiagnosis.

BACKGROUND: Organizing hematomas of the paranasal sinuses are diagnostic dilemmas clinically and radiographically, mimicking benign or malignant neoplastic processes and causing patients and clinicians undue worry regarding these diagnoses. Diagnostic criteria for correctly identifying these lesions are not well known. METHODS: A retrospective case series of 7 patients with sinonasal organizing hematoma was studied. Radiographic imaging, clinical characteristics, and pathology were reviewed for new insights. RESULTS: Three patients presented with a primary complaint of epistaxis, 4 had masses visible on nasal endoscopy, and 2 had vascular malformations or small hemangiomas adjacent to the mass found on final pathology. Biopsy of these masses were consistently nondiagnostic prior to complete resection. The most diagnostic findings were "shells" of T2 hypointensity on magnetic resonance imaging (MRI) surrounding the lobules of each of the masses. These correspond to rims of fibrosis at the periphery of the lobules on pathology. Areas of fresh hemorrhage are located at the center of these lobules. CONCLUSION: Sinonasal organizing hematomas are rare lesions of the paranasal sinuses whose clinical characteristics lead to misdiagnoses of benign or malignant neoplasms. Endoscopy, preoperative biopsy, and computed tomography (CT) imaging do not lend helpful information in differentiating these lesions from more worrisome neoplastic processes. However, MRI can lead to positive diagnosis by recognizing the distinct outer rims of T2 hypointensity typically seen in these lesions.

Clinical assessment is an accurate predictor of which patients will need septoplasty.

OBJECTIVES/HYPOTHESIS: Septoplasty is a frequently performed surgical procedure with the most common indication being nasal airway obstruction. Almost universally, health insurance companies mandate a trial of medical therapy consisting of intranasal corticosteroids prior to performance of septoplasty regardless of clinical assessment. Evidence for this requirement is lacking. We sought to evaluate the initial clinical assessment as a predictor of response to this mandated trial of medical treatment. STUDY DESIGN: Retrospective review of prospectively collected data on 137 consecutive patients who presented with symptoms of nasal obstruction and a deviated nasal septum on physical examination. METHODS: Patients were placed into one of three cohorts based on prediction of 1) failure of medical therapy with subsequent septoplasty, 2) success of medical therapy without subsequent septoplasty, or 3) unable to make a prediction. Patients from each cohort were assessed for subsequent response to medical therapy and ultimate need for septoplasty. RESULTS: Overall clinical assessment had a sensitivity of 86.9%, specificity of 91.8%, positive predictive value of 93.6%, and negative predictive value of 96.4% for detecting/predicting need for septoplasty. The accuracy of the overall clinical assessment is considerably better than severe deviation at any one septal anatomical site. Of patients whose response to medical therapy could not be predicted, 61.3% failed medical therapy and needed surgery; this is statistically equivalent to a 50/50 distribution between either needing septoplasty or not. CONCLUSIONS: Clinical assessment at initial presentation of patients with nasal obstruction and deviated septum is highly accurate in predicting which patients will need septoplasty.

Role of osteoplastic frontal sinus obliteration in the era of endoscopic sinus surgery.

Objective. Determining the indications for osteoplastic frontal sinus obliteration (OFSO) for the treatment of inflammatory frontal sinus disease. Study Design. Retrospective case series from a single tertiary care facility. Methods. Thirty-four patients who underwent OFSO for chronic frontal sinusitis (n = 23) and frontal sinus mucocele (n = 11) comprised our study group. Data reviewed included demographics, history of prior frontal sinus operation(s), imaging, diagnosis, and operative complications. Results. The age range was 19 to 76 years. Seventy percent of patients with chronic frontal sinusitis underwent OFSO as a salvage surgery after previous frontal sinus surgery failures, while 30% underwent OFSO as a primary surgery. For those in whom OFSO was a salvage procedure, the failed surgeries were endoscopic approaches to the frontal sinus (69%), Lynch procedure (12%), and OFSO outside this study period (19%). For patients with frontal sinus mucocele, 72% had OFSO as a first-line surgery. Within the total study population, 15% of patients presented for OFSO with history of prior obliteration, with a range of 3 to 30 years between representations. Conclusions. Osteoplastic frontal sinus obliteration remains a key surgical treatment for chronic inflammatory frontal sinus disease both as a salvage procedure and first-line surgical therapy.

An evidence-based review of endoscopic frontal sinus surgery.

BACKGROUND: Endoscopic approaches to treat frontal sinus disease gained in popularity over the past 20 years with a plethora of published studies that emphasize the high success rate of such surgeries. This study was designed to determine the levels of clinical evidence in the otolaryngology literature that address the efficacy of endoscopic approaches in the management of frontal sinus disease including frontal sinusitis. METHODS: Twenty-three publications that reported the surgical outcomes of endoscopic approaches to treat frontal sinus disease were reviewed. Data were collected regarding the study design, operative technique, number of patients, duration of follow-up, diagnostic method, surgical success rate, and method(s) used to assess surgical outcome. RESULTS: The study designs were a retrospective case series without control (16 articles), prospective case series without control (3 articles), and retrospective case series with internal control (4 articles). Eighty-three percent of the published articles provide an evidence level of IV, while the remaining 17% provide an evidence level of III. The surgical technique was described as frontal sinusotomy (n = 4), frontal sinusotomy or frontal sinus drillout (n = 1), frontal sinus drillout alone (n = 1), endoscopic modified Lothrop procedure (n = 9), Draf types I, II, or III (n = 6); trans-septal frontal sinusotomy (n = 1); and frontal sinus rescue procedure (n = 1). The mean number of subjects was 44, and the average follow-up period was 23.6 months. Surgical success rate ranged from 50 to 100%. CONCLUSION: Despite the number of reports in the literature that address the surgical outcome of endoscopic approaches for treatment of frontal sinus disease, the majority of these studies have a small population size, short follow-up period, and provide a low clinical evidence level.

Reformation of concha bullosa following treatment by crushing surgical technique: implication for balloon sinuplasty.

OBJECTIVES/HYPOTHESIS: There are various surgical techniques designed to treat conchae bullosae (CB). These include partial or total resection and crushing. Frontal sinus balloon sinuplasty is thought to work by the crushing/remodeling of the agger nasi and frontal recess air cells. The long-term outcome of sinuplasty in the frontal/ethmoid air cell region is unknown. To date, no study has been done on the reformation of CB after crushing. We report on the long-term outcome of a series of patients who underwent crushing of their CB and suggest implications for frontal sinus balloon sinuplasty. STUDY DESIGN: Retrospective case series. METHODS: Retrospective review of 10 patients who re-presented with CB as a component of their nasal obstructive symptoms despite previously undergoing crushing of their CB. Data analyzed included paranasal sinus computed tomography (CT) scans and operative reports. RESULTS: These 10 patients re-presented with recurrent rhinosinusitis and nasal obstructive symptoms. The patients had previously undergone septoplasty surgery with crushing of the CB and were noted to have reformed the CB on their most recent sinus CT. The previous surgeries were preformed from 2 to 15 years prior to their representation. CONCLUSIONS: CB can reform following crushing technique. One may extrapolate that agger nasi and frontal recess air cells may reform following balloon sinuplasty leading to recurrent obstruction of the frontal sinus outflow tract.

Connexin 26 and 30 genes mutations in patients with chronic rhinosinusitis.

OBJECTIVES: Connexin proteins play an important role in cell-to-cell communication. Mutations in the genes that encode for these connexins may potentially lead to dysfunction in mucociliary clearance predisposing to chronic rhinosinusitis (CRS) or recurrent acute rhinosinusitis (RARS). The objective of this study was to assess for the presence of connexin 26 and 30 gene mutations in patients with CRS and RARS. STUDY DESIGN: Prospective case series. METHODS: Forty-six consecutive patients who were diagnosed with CRS or RARS at a single tertiary care facility were included in the study. Patients with known dysfunction in mucociliary clearance were excluded. The following clinical data were collected: age, gender, duration of disease and age at onset, personal history of otitis media and/or sensorineural hearing loss (SNHL), and family history of paranasal sinus disease and SNHL. Buccal swab deoxyribonucleic acid (DNA) specimens were sequenced for connexin 26 and 30 genes. RESULTS: The study group consisted of 32 females and 14 males, 8 children and 38 adults. Adequate sequencing of connexin 30 gene was possible in all 46 specimens, but in only 19 specimens for connexin 26 gene. Connexin 30 gene mutations were not detected in any of the 46 specimens. Two of the 19 specimens had heterozygous mutations in the connexin 26 gene; there was one V371 mutation and one 35dG mutation. Both patients were adults; the patient with 35dG mutation had SNHL. CONCLUSION: Mutations in connexin 26 and 30 genes are rare in patients with CRS or RARS and do not seem to play a contributory role in the pathogensis of these disorders.

Predictors of prolonged length of stay after major elective head and neck surgery.

OBJECTIVE/HYPOTHESIS: Longer length of stay (LOS) after elective surgery is associated with an increased use of health care resources and higher costs. The objectives of this study were to determine the perioperative factors that predict a prolonged LOS after elective major head and neck operations and to test the hypothesis that factors related to process of care (intra- and postoperative) independently predict prolonged LOS after adjustment for preoperative patient characteristics. STUDY DESIGN: Prospective hospital-based cohort study. METHODS: The National VA Surgical Quality Improvement Program data were accessed for seven head and neck operations: radical neck dissection (RND) (n = 398), modified RND (n = 891), total laryngectomy (n = 431), total laryngectomy with RND (n = 747), hemiglossectomy with unilateral RND (n = 201), composite resection (n = 105), and composite resection with RND (n = 312). Prolonged LOS was defined as exceeding the 75th percentile for the LOS distribution of each operation. Multivariable logistic regression analysis was performed to identify factors that predicted prolonged LOS. RESULTS: Sixty-eight variables were analyzed among 3,050 patients who qualified for inclusion. Preoperative patient characteristics that predicted prolonged LOS were older age, poorer functional status, consumption of more than two drinks of alcohol per day, history of chronic obstructive pulmonary disease, and diabetes mellitus. Intraoperative processes that predicted prolonged LOS were a longer operative time and transfusion of erythrocytes. The postoperative variables that predicted a prolonged LOS were a return to the operating room within 30 days of the index operation and the occurrence of two or more operative complications. CONCLUSION: Several intraoperative processes and postoperative adverse events contributed additional predictive information for prolonged LOS, after consideration of preoperative patient characteristics.

Staphylococcus aureus and endoscopic sinus surgery.

PURPOSE OF REVIEW: The current recommendation for the choice of empiric antibiotic therapy of chronic rhinosinusitis is based on the bacteriology of acute rhinosinusitis. Staphylococcus aureus has been found consistently in cultures from patients with chronic rhinosinusitis. New studies have examined the role of Staphylococcus aureus in the pathogenesis and clinical course of chronic rhinosinusitis, both before and after surgical therapy. The consequence of antibiotic resistance, on the course of chronic rhinosinusitis and its treatment, has also been examined. RECENT FINDINGS: Several recent studies have confirmed past literature demonstrating a high incidence of sinus cultures positive for Staphylococcus aureus growth in patients with chronic rhinosinusitis. Moreover, one study reported that Staphylococcus aureus is common in patients with persistent chronic rhinosinusitis after endoscopic sinus surgery. These studies, however, have not shown that this bacterium is a significant factor in the development of chronic rhinosinusitis or a predictor of the severity of symptoms. Other studies did not support the notion of increased antibiotic resistance in chronic rhinosinusitis, although there is some evidence that antibiotic resistance may lead to refractory cases of the disease. The standard treatment, of multiple courses of empiric antibiotics followed by surgery, was not shown to increase the prevalence of methicillin-resistant Staphylococcus aureus. SUMMARY: A review of recent literature shows a high incidence of positive cultures for Staphylococcus aureus from the sinuses of patients with chronic rhinosinusitis, both before and after surgery, but has not produced convincing evidence that Staphylococcus aureus has a significant role in the pathogenesis or clinical course of the disease.

Correlation between middle turbinate and ipsilateral ethmoid histopathology in chronic rhinosinusitis.

OBJECTIVE: Study the concept of "rhinosinusitis" in patients with inflammatory paranasal sinus disease (IPSD). STUDY DESIGN AND SETTING: Prospective case control series in a tertiary care facility. Twenty-two consecutive patients with IPSD without polyposis were enrolled. A partial middle turbinectomy and ethmoidectomy were performed and the histopathologic findings of the surgical specimens from the 2 sites was studied. The general degree of inflammation, epithelial thickening, and inflammatory cell count were measured. RESULTS: The degree of middle turbinate inflammation correlated with that of the ipsilateral ethmoid sinus (Spearman's rho coefficient = 0.450; P < 0.05). Epithelial thickness was more prominent in the ethmoid sinus. The total inflammatory cell count was comparable. There was a statistically significant correlation among total inflammatory cell count, plasma cell count, and eosinophil count between the 2 sites. CONCLUSION: The ethmoid sinus inflammation in IPSD is accompanied by a commensurate ipsilateral middle turbinate inflammation. SIGNIFICANCE: The data support the use of the term "rhinosinusitis."

Correlation between preoperative clinical diagnosis and histopathological findings in patients with rhinosinusitis.

BACKGROUND: The diagnosis of chronic rhinosinusitis (CRS) or chronic rhinosinusitis with polyposis (CRSP) is typically clinical and based on the combination of medical history, physical examination, and imaging. The recommendation to perform surgery and the type of surgery is tailored to the diagnosis. The objective of this study is to determine the accuracy of preoperative clinical CRS or CRSP diagnosis in patients who underwent endoscopic sinus surgery. METHODS: This is a retrospective review of a case series of 380 consecutive patients who underwent endoscopic sinus surgery for the preoperative clinical diagnosis of CRS or bilateral CRSP. Data regarding symptoms, nasal endoscopy, computed tomography findings, preoperative diagnosis, and postoperative histopathology results were collected. RESULTS: The preoperative diagnoses were CRS (n = 180) and CRSP (n = 200). Two of the 180 patients (1.1%) with the preoperative diagnosis of CRS had a different postoperative histopathological diagnosis. The histopathology in both patients showed noncaseating granulomata, leading to a diagnosis of sarcoidosis. Nine of the 200 patients (4.5%) with the preoperative diagnosis of CRSP had a different postoperative histopathological diagnosis. Of these nine patients, five had inverted papilloma (bilaterally in one instance); one had adenocarcinoma; one had squamous-cell carcinoma; one had chronic invasive granulomatous fungal sinusitis; and one had sinonasal sarcoidosis. CONCLUSION: The preoperative clinical diagnosis can be inaccurate in patients with CRS and bilateral CRSP. The misdiagnosis is more common in CRSP, including patients with recurrent polyposis.