Venous malformation of the ethmoid and sphenoid sinuses.

OBJECTIVES: The aim of this study was to present a rare case of a venous malformation that occupied the ethmoid and sphenoid sinuses. Prior to resection, it was believed to be a hemangioma. METHODS: This study includes a case report and review of the literature. CONCLUSION: There is often confusion between "hemangiomas" and "vascular malformations," but they are important to differentiate because they have unique approaches to treatment. Venous malformations in the paranasal sinuses are very rare. To our knowledge, this is the first case report that explicitly describes a venous malformation in the ethmoid and sphenoid sinuses. It was treated using endoscopic sinus surgery with intraoperative computer-assisted stereotactic navigation.

The Impact of Pepsin on Human Nasal Epithelial Cells In Vitro: A Potential Mechanism for Extraesophageal Reflux Induced Chronic Rhinosinusitis.

OBJECTIVES: To describe potential mechanisms by which pepsin induces inflammation in refractive chronic rhinosinusitis (CRS). Our hypothesis was that pepsin induces mitochondrial damage and cytokine expression in human nasal epithelial cells (HNEpC) in vitro. METHODS: Western blot was used to detect pepsin in sinus lavages from patients with CRS and controls. The HNEpC cells were treated with pepsin (pH 7; 0.1 mg/mL) for 1 or 16 hours and routine electron microscopy (EM) and MTT assay were performed. Cytokine ELISA was performed on media collected from HNEpC cells 16 hours following a 1-hour pepsin treatment. RESULTS: Pepsin was detected in sinus lavages from 4 out of 6 CRS patients and 0 out of 3 controls. The EM showed mitochondrial damage in pepsin-treated HNEpC cells but not in control cells. The MTT assay demonstrated reduced mitochondrial activity in pepsin-treated HNEpC cells compared to controls (P < .001). Pepsin increased IL-1A (P = .003) and IL-6 (P = .04) expression in HNEpC cells. CONCLUSIONS: Pepsin in sinus lavages from patients with CRS is consistent with previous studies. This study reveals the damaging effect of pepsin on mitochondria in nasal epithelial cells in vitro. Cytokines previously associated with CRS were elevated following pepsin treatment of HNEpC cells in vitro. These results demonstrate mechanisms by which pepsin may potentiate CRS.

Use of coblation in resection of juvenile nasopharyngeal angiofibroma.

We present a series of 4 patients with juvenile nasopharyngeal angiofibroma (JNA) who underwent Coblation-assisted endoscopic resection after preoperative embolization, and discuss the use and advantages of endoscopic Coblation-assisted resection of JNA. Our limited case series suggests that Coblation may be used in the resection of JNA after embolization in a relatively safe, efficient, and effective manner. Coblation allows for decreased bleeding, less need for instrumentation, and improved visualization. There are limited published data in the literature to date on the use of Coblation in endoscopic JNA resection. We describe its use in a more extensive tumor than those previously reported. Further studies are needed to fully define the safety and utility of Coblation technology for this application.

Granulocyte transfusions in fulminant invasive fungal sinusitis.

PURPOSE: Fulminant invasive fungal sinusitis (IFS) is an aggressive disease seen in patients who are severely neutropenic. The use of granulocyte transfusions to address neutropenia-associated IFS has been described for almost 2 decades. The objectives are to provide our experience using granulocyte transfusions in patients with IFS and to provide a current review of the literature. MATERIALS AND METHODS: A retrospective chart review was performed at the Medical College of Wisconsin to identify patients who received granulocyte transfusions for IFS. Data collected included age, original diagnosis, IFS pathogen, dates, transfusion number, reason for discontinuation, additional therapies, last known follow-up, and status at last known follow-up. A Medline search and manual review of citations within bibliographies was also performed. RESULTS: A total of 20 patients received granulocyte transfusions at the Medical College of Wisconsin between October 2003 and June 2009; 3 of these patients received granulocyte transfusions for fulminant IFS. A total of 22 reported cases of IFS treated with granulocyte transfusions exist in the current literature. CONCLUSIONS: Although limitations to the use of granulocyte transfusions exist, they still represent a viable treatment option in individuals who fail to respond to more conventional therapies.

Oral corticosteroid use and the risk of developing avascular necrosis: A large retrospective review.

INTRODUCTION: The risk of adverse events, specifically avascular necrosis (AVN), associated with corticosteroid use is not well reported. The aim of this study was to evaluate the prevalence of AVN among patients with prior oral corticosteroid administration. METHODS: An institutional database query recognized 113,734 adult patients with oral corticosteroid administration between January 2006 and May 2017. A temporal query performed on this cohort determined that 789 had a diagnosis of AVN following oral corticosteroids. A retrospective review was performed on this cohort. Data collected included demographics, comorbidities, date of initial oral corticosteroid exposure, and time to diagnosis of AVN. Records without radiographic confirmation of AVN were excluded from analysis. Patients with cumulative lifetime dosages greater than 10,000 mg prednisone were excluded from analysis. RESULTS: A total of 789 patients with oral corticosteroid use prior to diagnosis of AVN were identified. Five hundred and seventy-two patients were excluded due to insufficient documentation of oral corticosteroid dosage, no radiographic evidence supporting the diagnosis of AVN, insufficient data confirming the temporal relationship between oral corticosteroids and AVN, and/or a cumulative dosing of >10,000 mg prednisone. This left 217 patients included in the analysis. The mean duration of use prior to diagnosis of AVN was 219 (± 374) days, and mean cumulative dose was 3314 (± 2908) mg prednisone equivalents. Mean time between diagnosis of AVN and onset of pathologic fracture was 379 (± 1046) days. CONCLUSION: For patients receiving low cumulative doses of oral corticosteroids, corticosteroids pose a small risk of development of AVN. More studies are required to better characterize risk.

Surgical Field Visualization during Functional Endoscopic Sinus Surgery: Comparison of Propofol- vs Desflurane-Based Anesthesia.

OBJECTIVE: To assess if the type of general anesthetic affects bleeding and field visualization during endoscopic sinus surgery. STUDY DESIGN: Prospective, randomized, controlled trial. SETTING: Academic teaching hospital and Veterans Affairs hospital in the United States. SUBJECTS AND METHODS: Seventy patients were randomized to 1 of 3 anesthetic regimens: (1) the volatile anesthetic desflurane (n = 22), (2) intravenous anesthesia with propofol (n = 25), or (3) a combination of propofol and desflurane (n = 23). Intravenous remifentanil was titrated to decrease the mean arterial pressure to 60 to 70 mm Hg but not ≥30% from baseline. Surgical bleeding scores were recorded along with bleeding rates and hemodynamic parameters, including cardiac output and systemic vascular resistance through pulse contour analysis from a radial arterial line. Statistics: multiple comparison tests and regression analyses; α = .05. RESULTS: There were no differences in bleeding rate (median, 0.58, 0.85, 0.57 mL min-1), bleeding score (2.1, 2.0, 2.0), surgery duration (79, 81, 86 minutes), extubation time (9, 7, 8 minutes), recovery room time (65, 61, 61 minutes), or any hemodynamic parameters among groups 1 through 3, respectively. Group 1 required lower remifentanil infusions than group 2 (0.11 vs 0.26 µg kg-1 min-1; P = .01). The bleeding score correlated positively with height (P = .014) and the Lund-MacKay score (P = .013). Bilateral vs unilateral surgery led to longer surgery duration (P = .001) and recovery room time (P = .004). CONCLUSION: When remifentanil is used for controlled hypotension, propofol has no advantage over desflurane to improve surgical field visualization during functional endoscopic sinus surgery.

Correlation of salivary and nasal lavage pepsin with MII-pH testing.

OBJECTIVES: Laryngopharyngeal reflux (LPR) is a common upper airway disease. Salivary pepsin is a proposed marker for LPR; however, the optimal time for collection of specimens for pepsin detection and pepsin's presence in the oral and nasal secretions relative to concurrent multichannel intraluminal impedance-pH (MII-pH) monitoring are unknown. STUDY DESIGN: Prospective case-control study with an experimental design. METHODS: Patients undergoing MII-pH testing for evaluation of LPR and asymptomatic control subjects were selected. Nasal lavage and saliva samples were collected in the clinic prior to MII-pH probe placement. Additional saliva samples were obtained an hour after each meal and upon waking the following morning. Nasal lavage and salivary pepsin were measured by ELISA. RESULTS: Twenty-six patients undergoing MII-pH testing and 13 reflux-free control patients were enrolled. Salivary pepsin was detected in 11 of 26 patients with suspected LPR and 0 of 13 controls. Pepsin was most frequently detected in the specimen provided upon waking at an average concentration of 186.9 ng/mL. A significant correlation was observed between salivary pepsin in waking samples to MII-pH measurements, including reflux bolus duration, and proximal and distal recumbent reflux episodes (P < 0.05). A significant correlation was also observed between salivary pepsin upon waking or sinus lavage and reflux symptom index (P < 0.05). CONCLUSION: Pepsin in salivary and nasal lavage samples demonstrated an association with MII-pH-documented LPR. Pepsin detection was most frequent in morning samples, supporting use of morning salivary pepsin levels as a potential noninvasive technique for LPR diagnosis. LEVEL OF EVIDENCE: 2 Laryngoscope, 130:961-966, 2020.

Odontogenic sinusitis: A review of the current literature.

OBJECTIVES: To present current literature on the topic of odontogenic sinusitis. DATA SOURCE: PubMed literature search for odontogenic sinusitis. RESULTS: Odontogenic sinusitis is an inflammatory condition of the paranasal sinuses that is the result of dental pathology, most often resulting from prior dentoalveolar procedures, infections of maxillary dentition, or maxillary dental trauma. Infections are often polymicrobial with an anaerobe-predominant microbiome requiring special considerations for antimicrobial therapy. Medical management and treatment of the underlying dental pathology remains a critical initial step in the treatment of odontogenic sinusitis, however recent literature suggests that a significant portion of patients may require endoscopic sinus surgery for successful disease resolution. CONCLUSIONS: This review describes the essential epidemiological and etiological factors, relevant clinical findings and diagnostic modalities, microbiologic and antimicrobial considerations, as well as the medical and surgical treatment approaches commonly utilized for the management of odontogenic sinusitis. LEVEL OF EVIDENCE: NA.

Tissue and fluid penetration of garenoxacin in surgical patients.

BACKGROUND AND PURPOSE: Garenoxacin is a novel des-F(6)-quinolone that exhibits broad-spectrum activity against a wide range of aerobic and anaerobic pathogens of clinical importance. This study examined the penetration of garenoxacin into sinus mucosa, incisional skin, subcutaneous tissue, bile, adipose tissue, striated muscle, bone, gallbladder wall, liver, small and large bowel mucosa, and mesenteric lymph nodes relative to the plasma concentration after an oral 600 mg dose. METHODS: A series of 30 patients, ages 20 to 83 years, undergoing elective surgery were enrolled. Patients received a single 600 mg oral dose of garenoxacin before surgery. Blood and tissue specimens were collected at surgery 3-5 h post-dose, and garenoxacin concentrations were determined using validated liquid chromatography/tandem mass spectrometry assays designed specifically for each tissue and biofluid. RESULTS: The mean plasma or bile (mcg/mL) and tissue (mcg/g) concentrations ( +/- standard deviation) were plasma 5.71 +/- 3.44, bile 7.59 +/- 9.96, adipose tissue 0.90 +/- 0.54, subcutaneous tissue 1.19 +/- 1.23, incisional skin 3.06 +/- 1.74, striated muscle 3.92 +/- 2.54, bone 2.82 +/- 2.42, sinus mucosa 5.26 +/- 3.84, liver 1.84 +/- 0.75, gallbladder 11.59 +/- 11.94, large intestine 12.13 +/- 9.34, small intestine 15.66 +/- 19.20, and mesenteric lymph node 3.10 +/- 2.44. CONCLUSION: After a single 600 mg oral dose, garenoxacin penetrates well into selected tissues and fluids. In addition, the tissue and fluid concentrations at 3-5 hours post-dose exceeded the minimum inhibitory concentration-90% of most targeted pathogens, suggesting that garenoxacin would be effective in the treatment of sinus, skin and skin structure, and intra-abdominal infections.

Autonomic dysfunction, allergy and the upper airway.

PURPOSE OF REVIEW: The autonomic nervous system has been implicated in the pathophysiology of chronic upper airway inflammatory disease for decades. We discuss the most recent literature with regard to autonomic nervous system dysfunction and chronic upper airway disease. RECENT FINDINGS: Recently, state of the art autonomic nervous system testing has demonstrated autonomic nervous system dysfunction in patients with chronic upper airway inflammatory disease. This dysfunction has been characterized as hypoadrenergic. SUMMARY: Autonomic nervous system dysfunction likely plays a role in chronic upper airway inflammatory disease. Further investigation may lead to a better understanding of the role of autonomic nervous system dysfunction in these disorders and, hence, opportunities for novel therapeutic modalities.

Endoscopic CSF leak repair.

PURPOSE OF REVIEW: The purpose of this review is to discuss endoscopic management of cerebrospinal fluid leaks and to highlight recent advances in both outcomes and technique. RECENT FINDINGS: Endoscopic techniques targeting the repair of skull-base defects have evolved as instrumentation for intranasal use has developed. The principles of endoscopic repair mirror those of open repair, with emphasis placed on site identification, site preparation, accurate graft placement and postoperative management. Several patient factors will affect the surgical and medical care of patients with cerebrospinal fluid rhinorrhea, including location, cause and overall medical condition. Numerous techniques have been described and large series attest to high success rates. The use of radiographic image-guidance systems promises to advance localization of the leak site. Endoscopic repair of cerebrospinal fluid leaks remains an accurate and complete method for the repair of cerebrospinal fluid leaks with decreased operative morbidity. SUMMARY: Endoscopic repair of anterior skull-base defects has a high success rate and markedly decreased morbidity as compared with traditional intracranial approaches. The endoscopic approach should be considered the technique of choice for repair of most cerebrospinal fluid fistulae and skull-base defects.

Autonomic nervous system evaluation in allergic rhinitis.

OBJECTIVES: To evaluate the relationship between allergic rhinitis (AR) and autonomic nervous system (ANS) dysfunction. METHODS: Quantitative ANS testing was completed in 10 patients with AR confirmed by clinical findings and allergy testing. This data was compared to 16 age-matched controls. RESULTS: ANS scores were significantly abnormal in AR patients when compared to normal controls. The composite autonomic scale score for the AR group was significantly impaired when compared to controls (1.6 vs 0.63, P < 0.0001). Additionally, subscore values quantifying the level of dysfunction within the sympathetic nervous system (1.0 for sudomotor and 0.5 adrenergic) were found to be significantly different (P < 0.0001 and 0.018). The mean subscore value quantifying the level of dysfunction within the parasympathetic system (cardiovagal) was not found to be significantly different from controls (P = 0.38). CONCLUSIONS: ANS dysfunction, specifically sympathetic hypofunction, was identified in all of the allergic rhinitis patients studied. Further characterization of the type of ANS abnormality may allow the development of novel pharmacologic therapies for these disorders.

Sex differences in outcomes of sinus surgery.

PURPOSE: Sex has been demonstrated to affect outcome in many diseases. Our current aim is to investigate the relationship between sex and outcomes of endoscopic sinus surgery (ESS) in patients with chronic rhinosinusitis (CRS). METHODS: Forty-four males and 73 females undergoing ESS for CRS with a mean follow-up of 1.4 years were evaluated prospectively. Computed tomography (CT), endoscopy, and quality of life (QOL) assessment was performed. Univariate analyses were performed to evaluate whether sex was predictive of outcome. Multiple logistic regression analysis was performed to evaluate sex association with patient factors predictive of outcome. RESULTS: Although no sex differences in CT and endoscopy were observed (CT, P=.107 and endoscopy, P>.1), females consistently scored worse than males on disease-specific QOL pre- and postoperatively. Importantly, there was no effect of sex on improvement/change scores for the QOL instruments. PREDICTIVE MODELS AND MULTIPLE LOGISTIC REGRESSION ANALYSIS: Sex was not found to be predictive of QOL or endoscopic outcome. Female sex was, however, associated with acetylsalicylic acid (ASA) intolerance and depression, both factors that have been associated with poorer outcome. CONCLUSION: Despite similarities in objective disease measures, females report significantly worse QOL scores pre- and postoperatively. Postoperative improvement did not differ by sex, nor was sex predictive of postoperative outcome. Sex differences in QOL reflect sex differences in ASA intolerance and depression, both more prevalent in females.

The hypoplastic maxillary sinus and the orbital floor.

PURPOSE OF REVIEW: Hypoplastic maxillary sinus is a relatively rare clinical problem that has a variable presentation. The purpose of this article is to review the recent literature with regard to evaluation and treatment. RECENT FINDINGS: Most authors suggest that hypoplastic maxillary sinus results from the development of negative pressure resulting from an obstruction of maxillary sinus ventilation. Patients most frequently present with unilateral enophthalmos but some cases may be identified incidentally on imaging studies. SUMMARY: Hypoplastic maxillary sinus is a rare clinical entity with variable presentation. Evaluation and management are tailored to each individual patient's degree of disease and symptoms.

Advances in Surgery: Extended Procedures for Sinonasal Polyp Disease.

In the standard functional endoscopic sinus surgery (FESS) procedure, the amount of dissection is often determined by the extent of disease with the goal to preserve as much normal mucosa as possible while restoring ventilation and reestablishing mucociliary clearance. A subset of patients with chronic rhinosinusitis with nasal polyposis (CRSwNP), however, may continue to have persistent mucosal inflammatory and aggressive polyp regrowth despite standard FESS and maximal pharmacology therapy, leading to recurrent and recalcitrant disease. Advanced endoscopic surgery techniques such as the modified endoscopic medial maxillectomy, endoscopic modified Lothrop procedure, otherwise known as a Draf 3 frontal sinusotomy, and nasalisation or radical ethmoidectomy are extensive surgical procedures to maximize disease clearance while providing sizeable drainage pathways for effective postoperative surveillance and topical delivery of medications. Studies have shown a decreased risk of revision surgery as well as a longer time interval for revision surgery in patients with refractory CRSwNP who have undergone extensive sinus surgery for polyps.

Predictive factors and outcomes in endoscopic sinus surgery for chronic rhinosinusitis.

PURPOSE: To assess objective and quality of life (QOL) outcomes before and after endoscopic sinus surgery (ESS) in patients with chronic rhinosinusitis (CRS) and to determine preoperative factors that predict surgical outcome in these patients. METHODS: One hundred nineteen adult patients with CRS and a mean follow-up of 1.4 +/- 0.35 years were evaluated prospectively including the following patient factors: prior sinus surgery, polyps, asthma, acetylsalicylic acid intolerance (ASA), smoking, allergy, depression, and sex. Computed tomography (CT), endoscopy, and QOL assessment was performed. Predictive value of patient factors was determined based on change in endoscopy and QOL scores after ESS. RESULTS: Objective outcomes: preoperative CT scores were significantly worse in patients with polyps, asthma, and ASA, whereas CT score was unaffected by prior sinus surgery, smoking, allergy, depression, and sex. Patients with CRS demonstrated significant improvement on nasal endoscopy after ESS, but preoperative, postoperative, and change in scores were affected by certain patient factors. Endoscopy scores were significantly worse in patients with prior sinus surgery, polyps, asthma, and ASA, but these patients also experienced the greatest improvement in endoscopy scores. Smokers and patients with depression had the least change in endoscopy scores. QOL outcomes: patients with CRS experienced improvement in QOL after ESS. Pre- and postoperative QOL was positively affected by polyps and adversely affected by ASA, depression, and female sex, but these groups still experienced significant improvement in QOL scores. Pre- and postoperative QOL was unaffected by prior sinus surgery, asthma, smoking, and allergies, and all of these groups experienced significant improvement in QOL scores. Factors predictive of outcome: ASA and depression were predictive of worse outcome. Preoperative CT scores approached significance as being predictive of outcome. CONCLUSION: Surgical management of CRS was associated with significant improvement on objective and QOL measures; however, specific patient factors, in particular ASA and depression, predict poorer outcome. Preoperative CT may be a predictor of endoscopic and QOL outcome and deserves further study.

Autonomic function and dysfunction of the nose and sinuses.

Patients with inflammatory disorders of the upper airway exhibit varying degrees of ANS dysfunction, including the sympathetic, parasympathetic,and sensory components. Current evidence is insufficient with regard to the exact role of ANS dysfunction and its relationship to these disorders.Thus, the interaction of the ANS and sinonasal inflammation deserves further study.

Odontogenic sinusitis: a case series studying diagnosis and management.

BACKGROUND: Odontogenic sinusitis is a well-recognized, but understudied form of sinusitis. Odontogenic sinusitis requires unique diagnostic criteria and a treatment regimen that differs from non-odontogenic sinusitis. The purpose of this article is to present a case series of patients with odontogenic sinusitis in order to clarify key disease characteristics and management techniques. METHODS: Retrospective case series of 55 patients with odontogenic sinusitis. Each patient underwent chart and imaging review to analyze demographic factors, diagnostic criteria, clinical course, and management. RESULTS: Fifty-five patients were identified retrospectively. Forty-four were diagnosed at initial visit. Twenty-eight (64%) of these patients were diagnosed by computed tomography (CT) scan showing dental pathology, 11 (25%) by known temporal relationship to a dental procedure, and 5 (11%) by presentation with oral-antral fistula. Only 65% of radiology reports for all patients mentioned dental pathology. Overall, 21 (38%) patients had disease resolution. Of these, 7 (33%) resolved with endoscopic sinus surgery (ESS) alone, 7 (33%) resolved with concurrent ESS and dental surgery, 2 (10%) resolved with dental surgery alone, 2 (10%) resolved with ESS after failing dental surgery, 2 (10%) resolved with medical management alone, and 1 (5%) resolved with medical management after failing dental surgery. Forty-six (84%) patients had unilateral odontogenic sinusitis. The Lund-Mackay score for all patients was (mean ± standard deviation [SD]) 4.0 ± 3.2. CONCLUSION: Odontogenic sinusitis is often misdiagnosed. Radiology reports commonly do not mention dental pathology. Management of odontogenic sinusitis needs to be tailored to each individual patient and involves varying combinations of medical management, dental surgery, and ESS.

Calcification of the olfactory bulbs in three patients with hyposmia.

An estimated two million Americans suffer from chemosensory disorders. We present the clinical and imaging findings in three hyposmic patients with bilateral olfactory bulb calcification detected by CT. To our knowledge, these are the first cases of olfactory bulb calcification reported in the literature. A review of the literature concerning calcification of cranial nerves, olfactory neuritis, and the potential etiology and clinical significance of olfactory bulb calcification in our patients is presented.