Treatment of chronic rhinosinusitis with high-dose oral terbinafine: a double blind, placebo-controlled study.

OBJECTIVES: To evaluate antifungal terbinafine in patients with chronic rhinosinusitis. STUDY DESIGN: Randomized, double-blind, placebo-controlled multicenter pilot study. METHODS: Fifty-three adults with chronic rhinosinusitis received terbinafine 625 mg/day (n = 25) or placebo (n = 28) once daily for 6 weeks. Sinus secretions were collected at screening for mycology. Computed tomography was graded for extent of opacification at baseline and at week 6 using a modification of the Lund-Mackay scoring system. Patients recorded rhinosinusitis symptoms on a visual analogue scale and completed the Rhinosinusitis Disability Index. RESULTS: Positive fungal cultures were found in 41 of 53 patients (17 terbinafine, 24 placebo). (Two subjects from the Terbinafine group and one subject from the control group had no week 6 data). The mean opacification scores pre- and posttreatment for the entire study group improved from 24.2 to 22.5 in placebo (n = 26) and from 26.3 to 24.2 in terbinafine group (n = 23). The least squares means for percent change from baseline (SE) were -6.0 (8.7) for placebo compared with -7.2 (8.1) for terbinafine; 95% confidence interval for treatment difference (-18.9, 21.1); P = .91. Results were similar when only patients with positive fungal cultures were evaluated in the efficacy analysis. Investigator therapeutic evaluations and sinus symptom scores were not significantly different between the two groups at baseline or at treatment completion. CONCLUSION: Treatment with terbinafine failed to improve the symptoms or radiographic appearance of chronic rhinosinusitis even when nasal irrigation samples were positive for fungus on culture. One consideration is that the fungi isolated were not a major pathologic factor in this cohort. It is also possible that, even at high dose, terbinafine may not have maintained therapeutic levels in the nasal secretions.

Zenker's diverticulotomy using the KTP/532 laser.

Multiple forms of surgical treatment exist for Zenker's diverticulum. Appropriate treatment needs to be tailored based on the needs of the patient and the resources and skills of the surgeon. We have reviewed the available surgical options and presented a series of 10 patients treated with a new technique, the KTP/532 laser diverticulotomy. The diverticulotomy is particularly well-suited to the debilitated patient who cannot tolerate a prolonged operation or a prolonged postoperative recovery. The results of the technique are comparable with those of other forms of diverticulotomy, and it is concluded that the KTP/532 laser is a simple, safe, and effective form of surgical treatment with exciting potential for future use.

Antifungal activity against allergic fungal sinusitis organisms.

A review of more than 50 allergic fungal sinusitis (AFS) patients indicates that most patients experience postoperative recurrences once weaned from oral steroids, leaving a glaring need for improved treatment. Topical antifungal therapy has not been described for AFS, but it could potentially lower fungal antigen loads via postoperative irrigations. No information exists to direct the choice of antifungal agent. The purpose of this study was to identify the appropriate drug to use for postoperative irrigations in AFS patients. Twenty-two fungal cultures grown from 15 AFS patients were studied for in vitro susceptibility to five common antifungal drugs: ketoconazole, amphotericin B, itraconazole, nystatin, and fluconazole. Results demonstrated that ketoconazole and amphotericin B were the most effective. Clinical trials are indicated to evaluate the efficacy of these drugs as a supplement to current AFS treatment.

Hypopharyngeal diverticulum.

The diagnosis and surgical management of 26 patients with hypopharyngeal diverticulum treated in the Department of Otolaryngology of the Washington University Medical School from 1961 to 1973 is discussed. The surgical technique for external excision of the diverticulum is described in detail. Results and complications are presented. The surgical excision of hypopharyngeal diverticulum is a standard, safe, and proven method of management which can be expected to result in satisfactory long-term results with minimal morbidity.

Image-guided endoscopic surgery: results of accuracy and performance in a multicenter clinical study using an electromagnetic tracking system.

Image-guided surgery has recently been described in the literature as a useful technology for improved functional endoscopic sinus surgery localization. Image-guided surgery yields accurate knowledge of the surgical field boundaries, allowing safer and more thorough sinus surgery. We have previously reviewed our initial experience with The InstaTrak System. This article presents a multicenter clinical study (n=55) that assesses the system's capability for localizing structures in critical surgical sites. The purpose of this paper is to present quantitative data on accuracy and performance. We describe several new advances including an automated registration technique that eliminates the redundant computed tomography scan, compensation for head movement, and the ability to use interchangeable instruments.

Lacrimal drainage system injury in functional endoscopic sinus surgery. Incidence, analysis, and prevention.

Injury to the lacrimal drainage system with resultant epiphora is a complication of functional endoscopic sinus surgery. A study of 24 patients was conducted to determine the incidence and significance of lacrimal drainage system injuries during functional endoscopic sinus surgery. Intraoperative testing demonstrated seven occult injuries (15%) in 46 endoscopic procedures. Postoperative testing demonstrated diversion of lacrimal drainage into the middle meatus in two patients and spontaneous healing of the injured lacrimal drainage system with restoration of normal drainage in three of the patients available for follow-up testing. In no patient did epiphora develop. It is concluded that the nasolacrimal drainage system is in close proximity to the dissection cavity during functional endoscopic sinus surgery and, hence, is at risk for inadvertent injury. Occult damage to the nasolacrimal drainage system would appear to be a common event during functional endoscopic sinus surgery; however, the complication of postoperative epiphora is rare.

Diagnosis of allergic fungal sinusitis.

Allergic fungal sinusitis is a noninvasive disease first recognized approximately one decade ago. It accounts for approximately 6% to 8% of all chronic sinusitis requiring surgical intervention and has become a subject of increasing interest to otolaryngologists and related specialists. Although certain signs and symptoms, as well as radiographic, intraoperative, and pathologic findings, may cause the physician to suspect allergic fungal sinusitis, no standards have been defined for establishing the diagnosis. It is extremely important to recognize allergic fungal sinusitis and differentiate it from chronic bacterial sinusitis and other forms of fungal sinusitis because the treatments and prognoses for these disorders vary significantly. To delineate a set of diagnostic criteria, we prospectively evaluated our most recent 15 patients with allergic fungal sinusitis. An allergy evaluation confirmed atopy through a strong history of inhalant mold allergies, an elevated total immunoglobulin E level, or a positive result of a skin test or radioallergosorbent test to fungal antigens in 100% of patients. All 15 patients had nasal polyposis, and 8 of 15 had asthma. There was a unilateral predominance in 13 of 15 cases. A characteristic computerized tomography finding of serpiginous areas of high attenuation in affected sinuses was seen in all patients, and 12 of 15 patients had some degree of radiographic bone erosion. Pathologic examination uniformly revealed eosinophilic mucus without fungal invasion into soft tissue; Charcot-Leyden crystals and peripheral eosinophilia were each observed in 6 of 15 patients. Every patient had fungus identified on fungal smear, although only 11 of 15 fungal cultures were positive.(ABSTRACT TRUNCATED AT 250 WORDS)

Prognosis for allergic fungal sinusitis.

Allergic fungal sinusitis is a recently described clinical entity that has gained increased attention as a cause of chronic sinusitis. The diagnosis can be established by demonstrating (1) type I hypersensitivity confirmed by history, skin tests, or serology; (2) nasal polyposis; (3) characteristic CT scan; (4) eosinophilic mucus without fungal invasion into sinus tissue; and (5) positive fungal stain of sinus contents removed intraoperatively or during office endoscopy. The exact pathogenesis of allergic fungal sinusitis remains controversial, and no treatment modality has proved to be consistently effective. Several reports during the last decade have suggested that allergic fungal sinusitis recurs more frequently than chronic bacterial sinusitis, but no studies have specifically addressed the prognosis of allergic fungal sinusitis. During the past two and a half years, we have treated 26 patients with allergic fungal sinusitis. The treatment always included functional endoscopic sinus surgery, topical nasal steroids, postoperative nasal saline irrigations, and endoscopic cleaning in the office. Adjuvant medical therapy included systemic steroids, oral antifungals, a combination of systemic steroids and oral antifungals, or in some cases, no additional treatment. Outcome was graded subjectively as improved, unchanged, or worse. Mean follow-up was 14.5 months. Twenty-two of 26 patients were improved. In reviewing postoperative outcomes, we observed endoscopic recurrent disease that generally preceded patient symptoms. Consequently, we developed an endoscopic staging system to record postoperative clinical status. Use of this staging system allowed evaluation of various treatments and enabled classification of patient outcome. Nineteen of 24 patients examined with extensive follow-up had objective signs of recurrent disease. It appears that this is a chronic disease characterized by physical signs that appear before the return of subjective clinical symptoms.

Radiation exposure in paranasal sinus imaging.

Plain films of the paranasal sinus were the imaging technique most frequently used before the advent of computed tomography. With improved resolution, computed tomography imaging has become the standard for evaluating patients with disease of the paranasal sinuses. With the widespread availability of computed tomography scanning, patients are likely to undergo multiple examinations during the treatment of their disease. Concern has been raised over the radiation exposure to the patient, in particular, with regard to radiation-induced cataracts. The purpose of this study is to measure the radiation dose associated with a variety of techniques for imaging the paranasal sinuses. A cadaveric specimen with thermoluminescent dosimeters placed over the orbits was used to measure radiation exposure during plain-film imaging, limited computed tomography, standard axial and coronal computed tomography, thin-cut axial computed tomography, and thin-cut coronal computed tomography. The measured dose in all these techniques is less than 4% of the acute dose associated with cataract formation.

Transmucosal cricopharyngeal myotomy with the potassium-titanyl-phosphate laser in the treatment of cricopharyngeal dysmotility.

Cricopharyngeal dysfunction is a relatively uncommon disorder that is widely misunderstood. Cricopharyngeal dysmotility is thought to represent abnormal function of the upper esophageal or cricopharyngeal sphincter. The cause of this dysfunction is related to uncoordinated pharyngeal swallowing, achalasia, or a combination of these factors. Unfortunately, standard diagnostic tests have not consistently demonstrated a failure of the cricopharyngeal sphincter to malfunction; therefore, cricopharyngeal myotomy has been suggested as a diagnostic and therapeutic tool in the treatment of dysmotility. Our report focuses on the current trends in the diagnosis and treatment of cricopharyngeal dysfunction. We also present a case report of a transmucosal cricopharyngeal myotomy performed with the potassium-titanyl-phosphate (KTP) laser. The KTP laser was found to be relatively safe and effective and did not demonstrate significant morbidity. Our conclusion was that a transmucosal cricopharyngeal myotomy with the KTP laser may represent a viable alternative for patients with cricopharyngeal dysmotility.

Allergic fungal rhinosinusitis: perioperative management, prevention of recurrence, and role of steroids and antifungal agents.

Allergic fungal sinusitis can best be thought of as chronic fungal affectation (not an infection) of the sinuses to which the body's immune system hyperreacts, thereby creating significant inflammation, edema, obstruction, and polyposis. Currently it is felt that allergic fungal sinusitis requires both surgical and medical management. The effectiveness and required duration of the various medical treatments remain unknown and are under active investigation. Both surgical intervention and the use of systemic steroids are recommended in the treatment of allergic fungal sinusitis. Experience with surgical and medical management, follow-up of patients, and proposed treatment protocols are discussed.

Advances in postoperative care following functional endoscopic sinus surgery.

The ultimate success of functional endoscopic sinus surgery often is determined during the period of postoperative care. Final surgical results are greatly influenced by preoperative surgical planning and intraoperative decision-making. One goal of postoperative care includes the prevention of scar formation, such as middle turbinate collapse. Specific techniques include mucosal preservation, middle meatal spacer corticosteroids and culture-directed antibiotics.

Primary endoscopic management of the frontal sinus.

Surgical treatment of the frontal sinus continues to be an area of much interest and controversy. The complex anatomy and confined space of this region require the endoscopic surgeon to be knowledgeable and delicate to obtain a positive result. Proper instrumentation is crucial and continues to evolve over time. Postoperative endoscopic care is integral to the success of endoscopic frontal sinusotomy and the availability of proper office equipment to perform this care is critical. In most instances, the intranasal endoscopic approach can be accomplished successfully without the need for an external procedure.

Revision endoscopic frontal sinusotomy with mucoperiosteal flap advancement: the frontal sinus rescue procedure.

Frontal sinusitis after middle turbinate resection occurs because of stenosis of the frontal ostium by soft tissue scarring or residual bony fragments (which are pulled to the medial orbital wall by scar contracture). Standard endoscopic techniques cannot address this problem; however, revision endoscopic frontal sinusotomy with mucoperiosteal flap advancement (the frontal sinus rescue procedure) relieves this bony stenosis and incorporates a mucosal flap that minimizes postoperative stenosis.

The frontal sinus unobliteration procedure.

Although intranasal frontal sinusotomy can now be performed for most cases of chronic frontal sinusitis, the osteoplastic frontal sinus procedure with obliteration, unfortunately, still is considered by many to be the standard for chronic frontal sinusitis against that which other frontal sinus procedures are judged. Unobliterating the previously obliterated sinus is indicated for patients with evidence of frontal sinus pathology on CT or MR images and for patients with chronic symptoms with equivocal radiologic results. The reopened frontal sinus can be reventilated and remucosalized, or reobliterated with the placement of a new fat graft. Complete or partial auto-obliteration by new bone formation or fibrosis is another possible endpoint that can result when unobliteration is attempted.

Geographic variation in allergic fungal rhinosinusitis.

Allergic fungal rhinosinusitis (AFRS) has a worldwide distribution. This survey of 20 otolaryngologic practices throughout the United States confirmed a variation in the frequency of AFRS relative to endoscopic sinus procedures performed for all other diagnoses. The highest incidence occurred in Memphis, Tennessee at 23%, with three other southern practices reporting a frequency of at least 10%. In the northern locations the frequency ranged from 0 to 4%. No correlation with mould counts was demonstrated, possibly because of incomplete mould data relative to most of the surgical locations.

Tracheoesophageal speech following transmucosal pharyngeal myotomy with the potassium-titanyl-phosphate laser.

Successful communication following laryngectomy usually involves an electrolarynx or oesophageal speech. Only within the past decade has tracheoesophageal puncture been advocated for alaryngeal speech and evolved into the procedure of choice. Successful production of speech after total laryngectomy using tracheoesophageal speech may be impaired secondary to anatomical and functional difficulties. The primary limitation of tracheoesophageal speech is pharyngoesophageal spasm occurring in the upper oesophageal sphincter impeding airflow through this segment. Our report presents four patients who underwent a pharyngeal myotomy with the potassium-titanyl-phosphate (KTP) laser. Post-operatively, each patient was able to communicate with functional alaryngeal speech. A transmucosal pharyngeal myotomy may represent an alternative for patients with speech failure after tracheoesophageal puncture.