International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors.

BACKGROUND: Sinonasal neoplasms, whether benign and malignant, pose a significant challenge to clinicians and represent a model area for multidisciplinary collaboration in order to optimize patient care. The International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors (ICSNT) aims to summarize the best available evidence and presents 48 thematic and histopathology-based topics spanning the field. METHODS: In accordance with prior International Consensus Statement on Allergy and Rhinology documents, ICSNT assigned each topic as an Evidence-Based Review with Recommendations, Evidence-Based Review, and Literature Review based on the level of evidence. An international group of multidisciplinary author teams were assembled for the topic reviews using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses format, and completed sections underwent a thorough and iterative consensus-building process. The final document underwent rigorous synthesis and review prior to publication. RESULTS: The ICSNT document consists of four major sections: general principles, benign neoplasms and lesions, malignant neoplasms, and quality of life and surveillance. It covers 48 conceptual and/or histopathology-based topics relevant to sinonasal neoplasms and masses. Topics with a high level of evidence provided specific recommendations, while other areas summarized the current state of evidence. A final section highlights research opportunities and future directions, contributing to advancing knowledge and community intervention. CONCLUSION: As an embodiment of the multidisciplinary and collaborative model of care in sinonasal neoplasms and masses, ICSNT was designed as a comprehensive, international, and multidisciplinary collaborative endeavor. Its primary objective is to summarize the existing evidence in the field of sinonasal neoplasms and masses.

New Nasopharyngeal Flap for Posterior Skull-base Reconstruction: The Upper-Tongue Flap

Abstract Introduction Reconstructions of clival resection are still challenging, and additional reconstructive methods may be necessary to achieve full coverage of the skull-base defect in patients with middle- and lower-clivus disease. Objective To describe a new nasopharyngeal flap for the middle and lower clivus. Methods Using nasal endoscopy in a cadaver dissection, we demonstrated a new nasopharygeal flap to cover the lower and middle clival resection. Results We described a new nasopharyngeal flap capable of covering the lower and middle portion of the clivus. Discussion The new nasopharyngeal flap, called the upper-tongue flap, is particularly adequate as an alternative for the reconstruction of middle and lower clivus defects, and it is better used in association with a nasalseptal flap in cases in which the nasalseptal flap alone does not provide enough mucosal coverage. Conclusion The new nasopharyngeal flap can be used in the reconstruction of clival resection.

New Nasopharyngeal Flap for Posterior Skull-base Reconstruction: The Upper-Tongue Flap.

Introduction Reconstructions of clival resection are still challenging, and additional reconstructive methods may be necessary to achieve full coverage of the skull-base defect in patients with middle- and lower-clivus disease. Objective To describe a new nasopharyngeal flap for the middle and lower clivus. Methods Using nasal endoscopy in a cadaver dissection, we demonstrated a new nasopharygeal flap to cover the lower and middle clival resection. Results We described a new nasopharyngeal flap capable of covering the lower and middle portion of the clivus. Discussion The new nasopharyngeal flap, called the upper-tongue flap, is particularly adequate as an alternative for the reconstruction of middle and lower clivus defects, and it is better used in association with a nasalseptal flap in cases in which the nasalseptal flap alone does not provide enough mucosal coverage. Conclusion The new nasopharyngeal flap can be used in the reconstruction of clival resection.

Headache and Other Symptoms in Chiari Malformation Type I Are Associated with Cerebrospinal Fluid Flow Improvement After Decompression: A Two-Institutional Study.

OBJECTIVE: Chiari malformation type I (CMI) is a common neurologic condition and surgery is the standard treatment. We aim to establish the cerebrospinal fluid (CSF) flow change as a potential objective indicator of surgical efficacy to improve symptoms. METHODS: We performed a retrospective 2-center analysis of surgically treated patients with CMI. Qualitative CSF flow studies obtained preoperatively and postoperatively were analyzed by the neuroradiologist, seeking improvement in CSF flow. Symptom status, including headache and neck pain, were recorded. RESULTS: Forty-nine patients were identified between 2010 and 2017. The average age was 36 years, with 47 females. After decompression, CSF flow was improved in 41 patients (group A) and unchanged in 8 (group B). Group A and B had a mean age of 34 and 42 years (P < 0.05) and an average tonsillar herniation of 8.3 and 8.5 mm (P = 0.40), respectively. Group A had improved clinical outcomes, compared with group B (P = 0.024), more specifically, in headache (50% vs. 37%), neck pain (66% vs. 33%), dizziness (78% vs. 50%), vision symptoms (84% vs. 80%), and weakness (100% vs. 66%), respectively. Group B had the only patient who did worse on clinical follow-up. CONCLUSIONS: Patients with CMI often present with a constellation of symptoms. We showed a significant association between improved CSF flow after decompression and symptom alleviation. Further, our study suggests that the presence of improved CSF flow postoperatively could represent an objective indicator for improved patient outcomes.

Unilateral Intervention in the Sinuses of Rabbits Induces Bilateral Inflammatory and Microbial Changes.

Background: Chronic rhinosinusitis (CRS) is a globally prevalent inflammatory condition of the paranasal sinuses which severely impairs patients' quality of life. An animal model of unilateral sinusitis by transient sinus occlusion has been described previously in rabbits. The aim of this study was to characterise the sinusitis rabbit model by investigating temporal and bilateral changes in the bacterial community and mucosal inflammation. Methods: Development of sinusitis was achieved by endoscopically placing Merocel ® , a sterile nasal packing material, in the left middle meatus of six New Zealand white rabbits for four weeks. After a total period of 14 weeks, rabbits were assessed for sinusitis by endoscopic examination, magnetic resonance imaging (MRI) and histology. Swabs from the left and right middle meatus were obtained for bacterial community analysis at three time points (week 0, week 4, week 14) during the study. Results: Endoscopic evaluation showed unilateral inflammation in all animals examined after the 4-week blocking period and at week 14. Notably, inflammatory changes were also seen in the contralateral sinus of all animals at week 4. MRI images demonstrated unilateral sinus opacification at week 4 in two rabbits, and partial unilateral sinus opacification at week 14 in one rabbit only. Histological analyses revealed substantial spatial heterogeneity of mucosal inflammation with inconsistent findings across all animals. No significant differences in mucosal inflammatory markers (such as goblet cell hyperplasia, epithelial denudation and oedema) could be identified between nostrils at week 14. The bacterial community in the rabbit sinuses was heavily dominated by Helicobacter at week 0 (baseline). At the end of the blocking period (week 4), bacterial alpha and beta diversity were significantly increased in both nostrils. The bacterial community composition at week 14 had primarily returned to baseline, reflecting the endoscopic and radiological results. Conclusion: This study reaffirmed the ability for development of sinusitis without inoculation of any pathogens in a rabbit model. We were able to demonstrate bilateral sinonasal mucosal inflammation, by inducing unilateral sinus blockage, which resulted in significant changes to the sinonasal bacterial community. These findings may explain some of the clinical observations seen in CRS and warrant further research to reveal potential implications for its therapeutic management.

Longitudinal analysis of sinus microbiota post endoscopic surgery in patients with cystic fibrosis and chronic rhinosinusitis: a pilot study.

BACKGROUND: Cystic fibrosis is a debilitating, autosomal recessive disease which results in chronic upper and lower airway infection and inflammation. In this study, four adult patients presenting with cystic fibrosis and chronic rhinosinusitis were recruited. Culture and molecular techniques were employed to evaluate changes in microbial profiles, host gene expression and antimicrobial resistance (AMR) in the upper respiratory tract over time. METHODS: Swab samples from the sinonasal cavity were collected at the time of surgery and at follow-up clinics at regular time intervals for up to 18 months. Nucleic acids were extracted, and DNA amplicon sequencing was applied to describe bacterial and fungal composition. In parallel, RNA was used to evaluate the expression of 17 AMR genes and two inflammatory markers (interleukins 6 and 8) using custom qPCR array cards. Molecular results were compared with routine sinus and sputum culture reports within each patient. RESULTS: Bacterial amplicon sequencing and swab culture reports from the sinonasal cavity were mostly congruent and relatively stable for each patient across time. The predominant species detected in patients P02 and P04 were Pseudomonas aeruginosa, Staphylococcus aureus in patient P03, and a mixture of Enterobacter and S. aureus in patient P01. Fungal profiles were variable and less subject specific than bacterial communities. Increased expressions of interleukins 6 and 8 were observed in all patients throughout the sampling period compared with other measured genes. The most prevalent AMR gene detected was ampC. However, the prevalence of AMR gene expression was low in all patient samples across varying time-points. CONCLUSIONS: We observed a surprising degree of stability of sinonasal microbial composition, and inflammatory and AMR gene expression across all patients post sinus surgery.

The Frontal Sinus and Frontal Recess: Anatomical, Radiological and Surgical Concepts

Abstract Introduction The frontal sinus (FS) is the most complex of the paranasal sinuses due to its location, anatomical variations and multiple clinical presentations. The surgical management of the FS and of the frontal recess (FR) is technically challenging, and a complete understanding of its anatomy, radiology, main diseases and surgical techniques is crucial to achieve therapeutic success. Objectives To review the FS and FR anatomy, radiology, and surgical techniques. Data Synthesis The FS features a variety of anatomical, volumetric and dimensional characteristics. From the endoscopic point of view, the FR is the point of greatest narrowing and, to have access to this region, one must know the anatomical limits and the ethmoid cells that are located around the FR and very often block the sinus drainage. Benign diseases such as chronic rhinosinusitis (CRS), mucocele and osteomas are the main pathologies found in the FS; however, there is a wide variety of malignant tumors that can also affect this region and represent a major technical challenge to the surgeon. With the advances in the endoscopic technique, the vast majority of diseases that affect the FS can be treated according to Wolfgang Draf, who systemized the approaches into four types (I, IIa, IIb, III). Conclusion Both benign and malignant diseases that affect the FS and FR can be successfully managed if one has a thorough understanding of the FS and FR anatomy, an individualized approach of the best surgical technique in each case, and the appropriate tools to operate in this region.

The Frontal Sinus and Frontal Recess: Anatomical, Radiological and Surgical Concepts.

Introduction The frontal sinus (FS) is the most complex of the paranasal sinuses due to its location, anatomical variations and multiple clinical presentations. The surgical management of the FS and of the frontal recess (FR) is technically challenging, and a complete understanding of its anatomy, radiology, main diseases and surgical techniques is crucial to achieve therapeutic success. Objectives To review the FS and FR anatomy, radiology, and surgical techniques. Data Synthesis The FS features a variety of anatomical, volumetric and dimensional characteristics. From the endoscopic point of view, the FR is the point of greatest narrowing and, to have access to this region, one must know the anatomical limits and the ethmoid cells that are located around the FR and very often block the sinus drainage. Benign diseases such as chronic rhinosinusitis (CRS), mucocele and osteomas are the main pathologies found in the FS; however, there is a wide variety of malignant tumors that can also affect this region and represent a major technical challenge to the surgeon. With the advances in the endoscopic technique, the vast majority of diseases that affect the FS can be treated according to Wolfgang Draf, who systemized the approaches into four types (I, IIa, IIb, III). Conclusion Both benign and malignant diseases that affect the FS and FR can be successfully managed if one has a thorough understanding of the FS and FR anatomy, an individualized approach of the best surgical technique in each case, and the appropriate tools to operate in this region.

Experimental study on the effects of bismuth subgallate on the inflammatory process and angiogenesis of the oral mucosa / Estudo experimental sobre os efeitos do subgalato de bismuto no processo inflamatório e de angiogênese em mucosa bucal

ABSTRACT INTRODUCTION: Bismuth subgallate is a salt derived from heavy metal. The aim of this study was to evaluate the effect of this salt on some phases of healing. OBJECTIVES: To assess the effect of subgallate on mucosa and to evaluate the association between the use of bismuth subgallate and neogenesis of vessels in oral mucosal wounds. METHODS: This was a prospective and experimental study. This study used sixty rats, which were divided into control and experimental groups. The animals were submitted to a surgical procedure, which caused oral mucosal injury. A saline solution was applied on the wound of the control group, and in the experimental group, a solution of bismuth subgallate was administrated. RESULTS: The experimental group showed greater inflammatory reaction with increasing monomorphic proliferation. There was increased vessel proliferation in the control group. CONCLUSION: Bismuth subgallate had a negative influence on the healing process, delaying the rate of new vessel formation and optimal wound healing.

RESUMO INTRODUÇÃO: O subgalato de bismuto é um sal derivado de metal pesado. A ideia desta pesquisa é avaliar sua interferência em alguma das fases da cicatrização. OBJETIVO: Delinear a ação do subgalato em mucosas. Avaliar a relação entre a utilização do subgalato de bismuto e a neoformação de vasos nas feridas em mucosa oral, para evidenciar o possível benefício resultante do seu uso. MÉTODO: Estudo experimental, prospectivo. Utilizou-se sessenta ratos, que foram divididos igualmente em grupo controle e experimento. Foram submetidos a um procedimento cirúrgico onde foi feito uma lesão na mucosa oral dos animais, após, uma solução de soro fisiológico foi aplicada sobre a lesão do grupo controle e sobre a ferida do grupo experimento foi aplicada uma solução de subgalato de bismuto. RESULTADOS: o grupo experimento apresentou maior reação inflamatória com crescente proliferação monomórfica. Vasos: houve maior proliferação no grupo controle. CONCLUSÕES: concluiu-se que o subgalato de bismuto teve uma ação negativa no processo de cicatrização, atrasando a velocidade de formação dos neovasos e a cicatrização ideal da ferida operatória.

Experimental study on the effects of bismuth subgallate on the inflammatory process and angiogenesis of the oral mucosa.

INTRODUCTION: Bismuth subgallate is a salt derived from heavy metal. The aim of this study was to evaluate the effect of this salt on some phases of healing. OBJECTIVES: To assess the effect of subgallate on mucosa and to evaluate the association between the use of bismuth subgallate and neogenesis of vessels in oral mucosal wounds. METHODS: This was a prospective and experimental study. This study used sixty rats, which were divided into control and experimental groups. The animals were submitted to a surgical procedure, which caused oral mucosal injury. A saline solution was applied on the wound of the control group, and in the experimental group, a solution of bismuth subgallate was administrated. RESULTS: The experimental group showed greater inflammatory reaction with increasing monomorphic proliferation. There was increased vessel proliferation in the control group. CONCLUSION: Bismuth subgallate had a negative influence on the healing process, delaying the rate of new vessel formation and optimal wound healing.