Comparison of Current Staging Systems for Sinonasal Inverted Papilloma.

BACKGROUND: A staging system is essential for determining the optimal surgical approach and predicting postoperative outcomes for inverted papilloma (IP). Although staging systems based on the extent to which the location is occupied by an IP have been widely used, an origin site-based classification of IP using unsupervised machine learning algorithms has recently been reported. OBJECTIVE: To determine the most appropriate of five staging systems for sinonasal IP by comparing recurrence rates for each stage according to each of those systems. METHODS: Eighty-seven patients with sinonasal IP were enrolled in the study. Their tumors were retrospectively categorized according to the Krouse, Oikawa, Cannady, and Han staging systems, which are based on the extent of IP, and the Meng system, which is based on the site of origin. The rates of recurrence for each stage of the five systems were compared. RESULTS: Seven of the 87 patients (8.0%) had recurrences during an average 45.5 months (12-138 months) of follow-up. There were significant differences in disease-free survival between the stages specified by Han and Meng (p = 0.027 and p < 0.001, respectively), but not between the stages specified by Krouse, Oikawa, and Cannady (p = 0.236, 0.062, and 0.130, respectively). Cox proportional hazard models revealed that Meng system (adjusted hazard ratio [aHR] 4.32, 95% confidence interval [CI] 1.10-17.04) and presence of dysplasia (aHR 7.42, 95% CI 1.15-47.85) were significantly associated with recurrence. CONCLUSION: The staging systems proposed by Han and Meng were found to be accurate in terms of tumor recurrence. We recommend use of the Han staging system before surgery and the Meng system after intraoperative identification of the origin of the tumor.

Prelacrimal approach vs conventional surgery for inverted papilloma in the maxillary sinus.

BACKGROUND: The prelacrimal approach, termed endoscopic modified medial maxillectomy (EMMM), has recently been applied for treatment of inverted papilloma (IP) in the maxillary sinus. EMMM provides wider access to the maxillary sinus while preserving the inferior turbinate and nasolacrimal duct. METHODS: We reviewed patients with IP in the maxillary sinus to compare the surgical results obtained by conventional surgery (ie, endoscopic maxillary sinus antrostomy or in combination with the Caldwell-Luc approach) with those obtained by EMMM. RESULTS: All patients had a T3 on the Krouse staging system, and the average follow-up time was 46.0 months. Of the 18 patients in the conventional group, recurrence was seen in 3 patients (16.6%). No recurrence was seen in the 27 patients who showed preservation of the inferior turbinate and nasolacrimal duct, and no complications occurred in the EMMM group. CONCLUSIONS: EMMM is an effective surgical approach that reduces recurrence with fewer complications.

[Comparison of B-mode ultrasonography and computed tomography in the evaluation of maxillary sinusitis in pediatric patients].

The use of ultrasonography in the diagnosis of maxillary sinusitis in pediatric patients has been reported recently because of the improvement of the accuracy of ultrasound technology. We thus compared B-mode ultrasonography and computed tomography in the diagnosis of maxillary sinusitis in pediatric patients. Thirty-six maxillary sinuses in 18 patients (10 females, 8 males, ages ranging from 7-15 years with an average age of 10.4 years) were examined. Ultrasonography of the maxillary sinus was performed in the horizontal and the vertical direction. Paranasal computed tomography and B-mode ultrasonography were performed within a few days. In some of these patients the maxillary sinuses were examined with a fiberscope. Sensitivity, specificity, false-positive, false-negative, positive predictive value and negative predictive value of B-mode ultrasonography compared with computed tomography were 92.6%, 100%, 0%, 7.4%, 100% and 81.8%, respectively. It appeared that ultrasonography was more sensitive than X-ray imaging, because the sensitivity and specificity of X-ray imaging of the maxillary sinus in pediatric patients compared with CT was reportedly 70-80%. A meaningful correlation of ultrasonography and CT was accepted as an assessment of desease severity. There are some problems with diagnosis by ultrasonography. There is no differentiation of mucosal thicking, cyst and discharge and imaging are less useful in pediatric patients. Because of these reasons, clinical sign and views in the nose are important for a correct diagnosis in pediatric patients. Furthermore, the most suitable age range to diagnose maxillary sinusitis correctly in pediatric patients must be examined.

Long-term evaluation after endoscopic sinus surgery for chronic pediatric sinusitis with polyps.

OBJECTIVE: Long-term retrospective evaluation was performed of computed tomography (CT) images and endoscopic findings after endoscopic sinus surgery for 88 cases of chronic pediatric sinusitis with nasal polyps. The objective was to determine the appropriate duration of such postoperative evaluation for children. METHODS: Fifty-one patients had both sinusitis and nasal polyps (BSP group), and the surgical procedure was decided in consideration of each patient's age (for less than 10 years of age, polypectomy (n=12); for 10-13 years old, anterior ethmoidectomy plus opening of the fontanelle and nasofrontal duct (n=20); and for serious cases older than 13 years, total sinusectomy (n=19)). On the other hand, for cases of unilateral sinusitis with antrochoanal polyps (USP group), anterior ethmoidectomy plus opening of the fontanelle was performed regardless of the patient's age (n=37, 5-15 years old). RESULTS: The postoperative endoscopic findings indicated that the polyps had been eliminated in approximately 91% of total patients. Good postoperative findings of CT images in most patients of USP group are observed at one year after the operation like the same of the postoperative course of adult chronic sinusitis. On the other hand CT images in BSP group evaluated one year after the operation were rated as unchanged or worsened in approximately half of the patients. However, at 4 years after the operation nearly all the patients were rated as improved or better. In addition, comparison of the age at final observation and the postoperative course found a striking decrease in the proportion of unchanged and worsened patients aged 12 and above. CONCLUSION: Accordingly, it was concluded that there is difference of healing process after the operation between USP and BSP group. Postoperative evaluation of BSP group should be performed for 4 years and up to an age of at least 12 years although post-ESS following of USP group is similar to that of adult sinusitis.

Identification of specific gene expression profiles in fibroblasts derived from middle ear cholesteatoma.

OBJECTIVE: To investigate the role of fibroblasts in the pathogenesis of cholesteatoma. DESIGN: Tissue specimens were obtained from our patients. Middle ear cholesteatoma-derived fibroblasts (MECFs) and postauricular skin-derived fibroblasts (SFs) as controls were then cultured for a few weeks. These fibroblasts were stimulated with interleukin (IL) 1alpha and/or IL-1beta before gene expression assays. We used the human genome U133A probe array (GeneChip) and real-time polymerase chain reaction to examine and compare the gene expression profiles of the MECFs and SFs. SUBJECTS: Six patients who had undergone tympanoplasty. RESULTS: The IL-1alpha-regulated genes were classified into 4 distinct clusters on the basis of profiles differentially regulated by SF and MECF using a hierarchical clustering analysis. The messenger RNA expressions of LARC (liver and activation-regulated chemokine), GMCSF (granulocyte-macrophage colony-stimulating factor), epiregulin, ICAM1 (intercellular adhesion molecule 1), and TGFA (transforming growth factor alpha) were more strongly up-regulated by IL-1alpha and/or IL-1beta in MECF than in SF, suggesting that these fibroblasts derived from different tissues retained their typical gene expression profiles. CONCLUSIONS: Fibroblasts may play a role in hyperkeratosis of middle ear cholesteatoma by releasing molecules involved in inflammation and epidermal growth. These fibroblasts may retain tissue-specific characteristics presumably controlled by epigenetic mechanisms.

[Surgical management of subperiosteal abscess of the orbit].

Subperiosteal abscess is generally defined as the collection of pus between the periorbita and the orbital wall, and usually results from paranasal sinus infection. Early, appropriate evaluation and management observing signs and symptoms of orbital inflammation are required to prevent blindness. We report 5 cases of subperiosteal abscess caused by paranasal sinus problems. We used endoscopic ethmoidectomy with puncture or endonasal endoscopic drainage of the abscess and found orbital complications in 4. We used conservative therapy in 1 with no visual acuity. We discuss pathogenesis and surgical indications and approaches. Three of 4 patients with mild visual acuity and treated with surgical procedure were cured without sequalae. We successfully managed the superior subperiosteal abscess with an endoscopic endonasal approach. One of 4 patients who had severe vision loss, however, was cured without any recovery of loss of vision after surgical drainage to decrease orbital pressure. The endscopic endonasal approach is more useful in managing both sinus disease and orbital complications than external ethmoidectomy.

TNF-alpha and IL-4 regulate expression of fractalkine (CX3CL1) as a membrane-anchored proadhesive protein and soluble chemotactic peptide on human fibroblasts.

The CX(3)C chemokine, fractalkine (FKN, CX(3)CL1), has multiple functions and exists as two distinct forms, a membrane-anchored protein and a soluble chemotactic peptide that cleaves from the cell surface FKN. In this study, we first demonstrated the expression of FKN in tumor necrosis factor (TNF)-alpha- and interleukin (IL)-4-stimulated human fibroblasts. The induction of FKN was observed for both forms. We also demonstrated monocyte chemotactic activity in the culture supernatant from the fibroblasts stimulated with these cytokines. These results suggest that TNF-alpha- and IL-4-stimulated fibroblasts may play an important role in accumulation of monocytes at inflammatory sites.

TNF-alpha and IL-4 regulate expression of IL-13 receptor alpha2 on human fibroblasts.

Two interleukin 13 receptors (IL-13Rs) have been identified as IL-13Ralpha1 and IL-13Ralpha2. IL-13Ralpha1 is composed of a heterodimer consisting of IL-13Ralpha1 and IL-4 receptor alpha (IL-4Ralpha) as a signaling subunit. In contrast, IL-13Ralpha2 is known as a decoy receptor for IL-13. In this study, we investigated the expression of IL-13Rs on human fibroblasts. IL-13Ralpha2 was significantly up-regulated after stimulation with tumor necrosis factor-alpha (TNF-alpha) and/or IL-4. In contrast, IL-13Ralpha1 was constitutively detectable and was not up-regulated. After the induction of IL-13alpha2 by IL-4, STAT6 phosphorylation through IL-13Ralpha1 by IL-13 was inhibited. We also detected large intracellular pools of IL-13Ralpha2 in fibroblasts quantitatively. Furthermore, mobilization of the IL-13Ralpha2 protein stores from the cytoplasm to the cell surface was prevented by an inhibitor of protein transport, brefeldin-A. These results indicate that TNF-alpha and IL-4 synergistically up-regulate the expression of IL-13Ralpha2 decoy receptor on human fibroblasts by inducing gene expression and mobilizing intracellular receptors, and thus may down-regulate the IL-13 signaling.