Prevalence and risk factors of brain atrophy and associated confusion state among adults from three hospitals in northern Tanzania.

Introduction: brain atrophy is the reduction of brain volume often accompanied with cognitive changes. Despite the availability of computerized-tomography (CT) scanners in Tanzania, little is known about the magnitude of brain atrophy, its associated confusion state and the risk factors in adults. This study aimed to fill those knowledge gaps. Methods: a retrospective cross-sectional hospital-based survey was conducted in northern Tanzania using a sample size of 384 CT images of adults who underwent brain CT scans in three referral hospitals. CT images were evaluated using a diagonal brain fraction (DBF) method to determine the presence of brain atrophy. Data for other covariates were also collected. Results: we report a prevalence of 60.67% for brain atrophy and 35% for the associated confusion state. Association between confusion state and brain atrophy was statistically significant (χ2 = 21.954, p<0.001). Brain atrophy was prognosticated by: age (adjusted OR: 1.11; 95% CI [1.05, 1.20], p<0.001), smoking (adjusted OR: 6.97; 95% CI [2.12, 26.19], p<0.001), alcohol-consumption (adjusted OR: 11.87; 95% CI [3.44, 40.81], p<0.001), hypertension (adjusted OR: 61.21; 95 CI [15.20, 349.43], p<0.001), type-2 diabetes mellitus (adjusted OR: 15.67; 95% CI [5.32, 52.77], p<0.001) and white matter demyelination (adjusted OR: 13.45; 95% CI [4.66, 44.25], p<0.001). Conclusion: there is high prevalence of brain atrophy and associated confusion state among hospitalized adults in northern Tanzania. Reported prognostic factors for brain atrophy such as age, smoking, alcohol consumption, hypertension, type-2 diabetes mellitus and white matter demyelination could help focus interventions in this area.

EAST in Children with Allergic rhinitis: Experience from Indian Tertiary Centre.

Allergic rhinitis (AR) is recognized as a growing global health disease with considerable importance among children and adolescents. This study aims to study the clinical and sensitization profile of children with allergic rhinitis using EAST. All children presenting to pediatric ENT outpatient with a clinical diagnosis of AR were prospectively recruited. Detailed demographic and clinical history including self-reported allergens, predominant symptoms and associated comorbid conditions were obtained. Severity of symptoms was graded on a visual analogue scale. Specific Ig E antibodies to 20 inhalant allergens was measured using EAST (EUROIMMUN, Germany).The pattern of sensitization was analyzed with respect to age, symptoms, associated comorbid conditions and urbanization. We recruited 328 children with a clinical diagnosis of AR (Mean age 10.3 year, IQR 8-13 years) Nasal block was the predominant symptom across all age groups, sneezing became more troublesome during adolescence. In 191 children sera were tested for allergen specific IgE, 119 (62.3%) showed positive sensitization. The most common sensitization noted was for cockroach, followed by dust mite and pollens. Majority had polysensitization (73%). Those who were predominantly sneezers were more likely to be sensitized with indoor allergens (p < 0.05). Among the comorbid conditions, asthma and atopic dermatitis accounted for maximum non ENT physician visits. The pattern of sensitization did not vary with age, urbanization or comorbid condition. This study highlights the clinical and sensitization profile of children with AR in South East India. Various peculiarities of this community has been presented which needs further attention.

Dimensions of the Posterior Tympanotomy and Round Window Visibility Through the Facial Recess: Cadaveric Temporal Bone Study Using a Novel Digital Microscope.

To measure the width of the posterior tympanotomy in cadaveric temporal bones using the digital microscope and classify the round window visibility through it. In 17 cadaveric wet adult temporal bones, cortical mastoidectomy followed by posterior tympanotomy was performed, delineating the facial and chorda tympani nerves. Antero-posterior width of the facial recess was measured at the levels of oval window and round window with the help of a digital microscope and its software. Visibility of the round window through the facial recess was assessed and classified according to the St. Thomas Hospital classification. The mean antero-posterior width of the facial recess measured was 4.7 ± 0.6 mm at the level of oval window and 4.3 ± 0.7 mm at the level of round window. Round window visibility grading in bones studied were as follows-Type 1 (53%), Type 2a (24%), Type 2b (18%) and Type 3 (5%). Interobserver variability of the posterior tympanotomy measurements using the digital microscope was found to be 91.1% with a 95% confidence interval of 79 to 97% at the level of oval window and 94.1% with a 95% confidence interval (CI) of 87 to 98% at the level of round window. The visibility of the round window is not entirely dependent on the facial recess width at the round window level, suggesting that other factors like cochlear rotation may also contribute to its actual location. Measurements of micro distances with the help of digital microscope seems to be convenient, cost effective and accurate with good inter observer reliability.

Cannabis in Palliative Care: A Systematic Review of Current Evidence.

CONTEXT: Palliative care aims to improve the quality of life in patients with incurable illness. Medicinal cannabis (MC) has been used in the palliative care setting to address multiple symptoms in patients. OBJECTIVES: To evaluate the full scope of available literature investigating the effects and potential harms of MC on symptom management and quality of life in palliative care. METHODS: PubMed, Embase, The Cochrane Library and clinicaltrials.gov were searched for eligible articles, published between 1960 and September 9, 2021. Quality of the evidence was assessed in accordance with Grading of Recommendations, Assessment, Development and Evaluations. Risk of bias was assessed using the RoB 2 tool for randomised controlled trials and the Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I) tool for non-randomized trials. RESULTS: Fifty-two studies (20 randomised; 32 non-randomised) with 4786 participants diagnosed with cancer (n = 4491), dementia (n = 43), AIDS (n = 235), spasticity (n = 16), NORSE syndrome (n = 1) were included. The quality of evidence was 'very low' or 'low' for all studies, and low for only two randomised controlled trials. Positive treatment effects (statistical significance with P < 0.05) were seen for some MC products in pain, nausea and vomiting, appetite, sleep, fatigue, chemosensory perception and paraneoplastic night sweats in patients with cancer, appetite and agitation in patients with dementia and appetite, nausea and vomiting in patients with AIDS. Meta-analysis was unable to be performed due to the wide range of cannabis products used and the heterogeneity of the study outcomes. CONCLUSION: While positive treatment effects have been reported for some MC products in the palliative care setting, further high quality evidence is needed to support recommendations for its use in clinical practice.

A Three Point Assessment Protocol for Tympanoplasty Outcomes: A Retrospective Analysis

Abstract Introduction The surgical outcome of chronic otitis media (COM) of the mucosal type in the pediatric population with high rates of recurrent tympanic membrane perforation is indeed a concern for the attending surgeon. Objective The present study was done to evaluate the outcome of tympanoplasty in children with chronic otitis media mucosal type. Methods A retrospective analysis of the medical records of all children, aged < 16 years old, who underwent tympanoplasty for COM of the mucosal type was performed. These patients were addressed by a three-point assessment, for predicting outcome of tympanoplasty, which included the age of the patient, addressing the nasal/pharyngeal issues, and the status of the COM (discharging or dry). Surgical success was assessed in terms of graft uptake and improvement of hearing. Factors affecting the surgical outcome were also analyzed. Results A total of 90 children underwent type 1 tympanoplasty; 7 were lost to follow-up and 10 had incomplete audiometric results. In the 73 tympanoplasties analyzed, graft uptake was seen in 91.7% of the patients. Children with longer duration of ear discharge (> 8 years) had greater hearing loss. Children aged > 8 years old showed statistically significant higher chance of graft uptake (p = 0.021). Five of the six children who had graft rejection had bilateral disease. Conclusion A three-point assessment in the management of pediatric COM of the mucosal type offers good outcomes with post-tympanoplasty graft uptake rates > 90%.

Interplay of ERα binding and DNA methylation in the intron-2 determines the expression and estrogen regulation of cystatin A in breast cancer cells.

Despite advances in early detection and treatment, invasion and metastasis of breast tumors remains a major hurdle. Cystatin A (CSTA, also called stefin A), an estrogen-regulated gene in breast cancer cells, is an inhibitor of cysteine cathepsins, and a purported tumor suppressor. Loss of CSTA expression in breast tumors evidently shifts the balance in favor of cysteine cathepsins, thereby promoting extracellular matrix remodeling, tumor invasion and metastasis. However, the underlying mechanism behind the loss of CSTA expression in breast tumors is not known. Here, we have analyzed CSTA expression, and methylation of upstream and intron-2 CpG sites within the CSTA locus in human breast cancer cell lines and breast tumors of the TCGA cohort. Results showed an inverse relationship between expression and methylation. Sequence analysis revealed a potential estrogen response element (ERE) in the intron-2. Analysis of ChIP-seq data (ERP000380) and our own ChIP experiments showed that 17ß-estradiol (E2) enhanced ERα binding to this ERE in MCF-7 cells. This ERE was located amidst the differentially methylated intron-2 CpG sites, which provoked us to examine the possible conflict between estrogen-regulation of CSTA and DNA methylation in the intron-2. We analyzed the expression of CSTA and its regulation by E2 in MDA-MB-231 and T47D cells subjected to global demethylation by 5-azacytidine (5-aza). 5-aza significantly demethylated intron-2 CpGs, and enhanced estrogen-induced ERα occupancy at the intron-2 ERE, leading to restoration of estrogen-regulation. Taken together, our results indicate that DNA methylation-dependent silencing could play a significant role in the loss of CSTA expression in breast tumors. The potential of DNA methylation as an indicator of CSTA expression or as a marker of tumor progression can be explored in future investigations. Furthermore, our results indicate the convergence of ERα-mediated estrogen regulation and DNA methylation in the intron-2, thereby offering a novel context to understand the role of estrogen-ERα signaling axis in breast tumor invasion and metastasis.

Determination and analysis of agonist and antagonist potential of naturally occurring flavonoids for estrogen receptor (ERα) by various parameters and molecular modelling approach.

Most estrogen receptor α (ERα) ligands target the ligand binding domain (LBD). Agonist 17ß-estradiol (E2) and tamoxifen (TM, known SERM), bind to the same site within the LBD. However, structures of ligand-bound complexes show that E2 and TM induce different conformations of helix 12 (H12). During the molecular modelling studies of some naturally occurring flavonoids such as quercetin, luteolin, myricetin, kaempferol, naringin, hesperidin, galangin, baicalein and epicatechin with human ERα (3ERT and 1GWR), we observed that most of the ligands bound to the active site pocket of both 3ERT and 1GWR. The docking scores, interaction analyses, and conformation of H12 provided the data to support for the estrogenic or antiestrogenic potential of these flavonoids to a limited degree. Explicit molecular dynamics for 50 ns was performed to identify the stability and compatibility pattern of protein-ligand complex and RMSD were obtained. Baicalein, epicatechin, and kaempferol with 1GWR complex showed similar RMSD trend with minor deviations in the protein backbone RMSD against 1GWR-E2 complex that provided clear indications that ligands were stable throughout the explicit molecular simulations in the protein and outcome of naringin-3ERT complex had an upward trend but stable throughout the simulations and all molecular dynamics showed stability with less than overall 1 Å deviation throughout the simulations. To examine their estrogenic or antiestrogenic potential, we studied the effect of the flavonoids on viability, progesterone receptor expression and 3xERE/3XERRE-driven reporter gene expression in ERα positive and estrogen responsive MCF-7 breast cancer cells. Epicatechin, myricetin, and kaempferol showed estrogenic potential at 5 µM concentration.

Depictions of acne and psoriasis influence interpersonal aversion.

The presence of a dermatological condition may deter contact with the affected person because it falsely signals the threat of infection. The current study investigated interpersonal aversion towards individuals with the appearance of acne and psoriasis. Participants (N = 196) either viewed a female face with the appearance of acne, psoriasis, or no visible dermatological condition. Participants rated the attractiveness of the person, and indicated their willingness for social and indirect contact with them. The person depicted with acne was rated significantly less attractive than the person with psoriasis or no dermatological condition. Participants reported significantly less willingness for indirect contact with the person depicted with acne or psoriasis compared to the person with no visible dermatological condition. In contrast, participants expressed more willingness for social contact with a person with acne than with the person with psoriasis or no dermatological condition. Group differences were significant when controlling for attractiveness ratings. Unwarranted fear of infection might underpin avoidance and discriminatory behaviour towards those with skin conditions. Further research is required to understand factors that influence avoidance of contact.

Clinical Study on Middle Ear Diseases in Children with Orofacial Clefts.

Introduction Orofacial clefts are associated with middle ear diseases, but the magnitude of this problem is not generally well appreciated. The aim of this study was to describe the middle ear findings and audiological profile in children with orofacial clefts. Materials and methods Children with orofacial clefts attending plastic surgery and otorhinolaryngology departments of a tertiary hospital over one-year duration were included in this study. Ninety-six children with orofacial clefts were identified. They were categorized age-wise as zero to five years, more than five years to 10 years, and more than 10 years to 15 years. They underwent a detailed ear, nose, and throat examination followed by audiological tests, including brainstem evoked response audiogram (BERA), pure tone audiogram (PTA), and tympanometry. Results Among 96 children with orofacial clefts, only 24 children (25%) had symptomatic ear problems, whereas on ear examination, 56 children (58.3%) had abnormal ear findings. Middle ear effusion (MEE) was the most common ear condition, and it was seen in 94 ears (48.9%). Cholesteatoma was noted in six children (3.1%). Out of 73 children in the zero to five age group, 58 children (79.5%) did not have any history of ear problem but 55.5% (81 ears) had features of MEE such as a dull tympanic membrane (TM). In the age group of more than five years to 10 years, only four children (28.5%) were symptomatic. Five children (55.5%) out of nine in the age group of more than 10 years had a symptomatic ear problem of which four children (44.4%) had chronic otitis media squamosal disease. The earlier age groups showed a trend of ear disease being asymptomatic compared to older children. Normal hearing was present in only 40 children (41.7%) and various degrees of hearing loss were seen in 56 children (58.3%). The mean air conduction threshold in the age group zero to five years, more than five years to 10 years, and more than 10 years were 33±8.3 decibels (dB), 25±6.2 dB, and 31.5±14 dB, respectively. Out of 144 ears (72 children) in the asymptomatic group, 67 ears (46.5%) had normal hearing. Seventy-seven ears (53.5%) had some degree of hearing loss. Mean air conduction hearing loss in the asymptomatic group was 29.8±7.3 dB. Conclusion This study highlights the higher incidence of middle ear diseases compared to the presenting symptoms in children with orofacial clefts. This stresses on the need for a detailed otological evaluation to identify any middle ear pathology so that timely intervention can be taken.

Endoscopic Repair of CSF Rhinorrhea: An Institutional Experience.

INTRODUCTION: Endoscopic repair is considered the treatment of choice in cerebrospinal fluid (CSF) rhinorrhea. The aim of our study was to analyze the etiopathogenesis of CSF rhinorrhea, the outcome of treatment and the causes of failure in a developing-country setting. MATERIALS AND METHODS: A retrospective review of patients treated with endoscopic repair for CSF rhinorrhea at a tertiary care hospital in southern India from January 2002 to December 2009 identified 36 patients, the majority of them being women. The defects were closed in three layers using fat, fascia lata and nasal mucosa along with a fibrin sealant in the majority of the patients. Per-operatively, a subarachnoid drain was placed in all patients. Patients were followed up for 1 year. RESULTS: Spontaneous onset of CSF rhinorrhea was noted in 61% of patients. The most common site of leak was found to be the left cribriform plate area. Hence the most common cause of CSF rhinorrhea in our study was spontaneous and the second most common was post-traumatic. Our success rate on the first attempt at endoscopic repair was 100%, with a recurrence rate of 6%. A large defect, failure of localization of the defect, or other co-morbid conditions such as chronic cough may be the most likely causes of recurrence of leak. CONCLUSION: Accurate localization of the site of lesion using a high-resolution computed tomography (CT) scan with magnetic resonance imaging (MRI) and confirmation of the site of leak by intraoperative Valsalva maneuver along with multilayered closure of the dural defect and post-operative lumbar drain appear to be essential for the successful endoscopic repair of CSF rhinorrhea.

Histoplasmosis Presenting as a Laryngeal Ulcer in an Immunocompetent Host.

Histoplasmosis is a granulomatous disease of worldwide distribution caused by a dimorphic fungus Histoplasma capsulatum. Majority of primary infections in immunocompetent hosts are asymptomatic or may present with flu-like illness. Histoplasmosis may occur in three forms: (i) Primary acute pulmonary form, (ii) chronic pulmonary and (iii) disseminated form. The manifestations of disseminated form of histoplasmosis are fever, weakness, weight loss, hepatosplenomegaly, and mucocutaneous lesions. The mucosal involvement could be oropharyngeal or laryngeal involvement. We report an unusual case of histoplasmosis presenting as a laryngeal ulcer in an immunocompetent host.

Investigating the effects of probiotics on pneumococcal colonization using an in vitro adherence assay.

Adherence of Streptococcus pneumoniae (the pneumococcus) to the epithelial lining of the nasopharynx can result in colonization and is considered a prerequisite for pneumococcal infections such as pneumonia and otitis media. In vitro adherence assays can be used to study the attachment of pneumococci to epithelial cell monolayers and to investigate potential interventions, such as the use of probiotics, to inhibit pneumococcal colonization. The protocol described here is used to investigate the effects of the probiotic Streptococcus salivarius on the adherence of pneumococci to the human epithelial cell line CCL-23 (sometimes referred to as HEp-2 cells). The assay involves three main steps: 1) preparation of epithelial and bacterial cells, 2) addition of bacteria to epithelial cell monolayers, and 3) detection of adherent pneumococci by viable counts (serial dilution and plating) or quantitative real-time PCR (qPCR). This technique is relatively straightforward and does not require specialized equipment other than a tissue culture setup. The assay can be used to test other probiotic species and/or potential inhibitors of pneumococcal colonization and can be easily modified to address other scientific questions regarding pneumococcal adherence and invasion.

A 'biopsychosocial' model for recovery: a grounded theory study of families' journeys after a Paediatric Intensive Care Admission.

Paediatric intensive care has a significant impact on the children and families who experience it. This effect continues post-discharge as the family attempt to recover from their ordeal. This article begins with an exploration of what makes a Paediatric Intensive Care Unit (PICU) admission potentially so traumatising and then examines current models for recovery which exist in the literature. These remain sparse and do not provide a coherent model for recovery after PICU. This paper therefore presents research which aimed to develop a model to understand the recovery journey for families. Children who had been PICU patients and their parents were interviewed and the transcripts analysed using grounded theory. Participants highlighted the importance of physical, psychological and social recovery and these have been integrated into a biopsychosocial model of recovery. Finding and accepting a 'new normal' were the culmination of this biopsychosocial journey. This paper concludes that an integrated approach to recovery is necessary and makes some recommendations for further research and clinical practice.

Autoimmune hepatitis--SLE overlap syndrome.

Autoimmune hepatitis also known as Lupoid hepatitis is an autoimmune liver disease characterized by the presence of autoantibodies including antinuclear antibodies (ANA) and hyper gammaglobulinemia. SLE can be associated with hepatitis, which is referred to as lupus hepatitis. It is important to distinguish these two entities, as the course of the disease is different in both. It has also been noted that these two entities can co-exist when it is referred to as Autoimmune hepatitis--SLE overlap syndrome. We are reporting a case of Autoimmune hepatitis--SLE overlap syndrome in a 30 years old lady.

Lymphoplasmacytic lymphoma and IgA nephropathy in a patient with hepatitis C infection.

Hepatitis C virus (HCV) infection is known to be associated with lymphoplasmacytic lymphoma. Reports are available of IgA nephropathy along with HCV infection. We are reporting the case of a 44 years old male who was diagnosed to have Hepatitis C infection with lymphoplasmacytic lymphoma and IgA nephropathy.

Impact of HbAlc on acute cardiac states.

OBJECTIVES: To find out the impact of HbAlc levels on the severity and short term complications of patients with heart disease admitted to the Intensive Coronary Care Unit (ICCU). METHODS: One hundred and sixty six patients admitted to ICCU in 2006 with acute cardiac states (unstable angina, acute myocardial infarction, heart failure, cardiomyopathy) were prospectively studied. Patients were divided into two groups--Group A (diabetics) and Group B (non diabetics). Patients were followed up till the time of discharge. RESULTS: Out of the 166 patients, 92 were diabetic (group A) and 74 were non diabetic (group B). The mean HbAlc of group A was 8.4+1.9% and that of group B was 5.7+0.6%. Risk factors like dyslipidemia, hypertension, previous history of heart disease and triple vessel disease were found more in group A than in group B. History of smoking, positive family history of heart disease, and angina as a presenting symptom were more in group B. Complications like heart failure and post infarction angina occurred significantly more in patients with diabetes. In group A, unstable angina, ST elevation myocardial infarction, cardiac failure, accelerated hypertension, dilated cardiomyopathy and triple vessel disease were seen in a significantly higher proportion of patients with poor glycemic control (HbAlc>or=7%) compared to patients with HbAlc level<7%. In group B, 72/74 (97.2%) patients had HbAlc levels>or=5%, 68.8% of whom had HbAlc levels of >or=5.6%. CONCLUSION: Severity and complications of heart disease were significantly higher in diabetics and showed a significant correlation with HbAlc. A large number of non diabetics presenting with acute cardiac states i.e. 97.2%, had HbAlc values>or=5%.

Transcriptional repression of Caveolin-1 (CAV1) gene expression by GATA-6 in bladder smooth muscle hypertrophy in mice and human beings.

Hypertrophy occurs in urinary bladder wall smooth muscle (BSM) in men with partial bladder outlet obstruction (PBOO) caused by benign prostatic hyperplasia (BPH) and in animal models of PBOO. Hypertrophied BSM from the rabbit model exhibits down-regulation of caveolin-1, a structural and functional protein of caveolae that function as signaling platforms to mediate interaction between receptor proteins and adaptor and effector molecules to regulate signal generation, amplification, and diversification. Caveolin-1 expression is diminished in PBOO-induced BSM hypertrophy in mice and in men with BPH. The proximal promoter of the human and mouse caveolin-1 (CAV1) gene was characterized, and it was observed that the transcription factor GATA-6 binds this promoter, causing reduced expression of caveolin-1. Furthermore, caveolin-1 expression levels inversely correlate with the abundance of GATA-6 in BSM hypertrophy in mice and human beings. Silencing of GATA6 gene expression up-regulates caveolin-1 expression, whereas overexpression of GATA-6 protein sustains the transcriptional repression of caveolin-1 in bladder smooth muscle cells. Together, these data suggest that GATA-6 acts as a transcriptional repressor of CAV1 gene expression in PBOO-induced BSM hypertrophy in men and mice. GATA-6-induced transcriptional repression represents a new regulatory mechanism of CAV1 gene expression in pathologic BSM, and may serve as a target for new therapy for BPH-induced bladder dysfunction in aging men.

Cholinergic neurons regulate secretion of glial cell line-derived neurotrophic factor by skeletal muscle cells in culture.

Glial cell line-derived neurotrophic factor (GDNF) has been identified as a potent survival factor for both central and peripheral neurons. GDNF has been shown to be a potent survival factor for motor neurons during programmed cell death and continuous treatment with GDNF maintains hyperinnervation of skeletal muscle in adulthood. However, little is known about factors regulating normal production of endogenous GDNF in skeletal muscle. This study aimed to examine the role that motor neurons play in regulating GDNF secretion by skeletal muscle. A co-culture of skeletal muscle cells (C2C12) and cholinergic neurons, glioma×neuroblastoma hybrid cells (NG108-15) were used to create nerve-muscle interactions in vitro. Acetylcholine receptors (AChRs) on nerve-myotube co-cultures were blocked with alpha-bungarotoxin (α-BTX). GDNF protein content in cells and in culture medium was analyzed by enzyme-linked immunosorbant assay (ELISA) and western blotting. GDNF localization was examined by immunocytochemistry. The nerve-muscle co-culture study indicated that the addition of motor neurons to skeletal muscle cells reduced the secretion of GDNF by skeletal muscle. The results also showed that blocking AChRs with α-BTX reversed the action of neural cells on GDNF secretion by skeletal muscle. Although ELISA results showed no GDNF in differentiated NG108-15 cells grown alone, immunocytochemical analysis showed that GDNF was localized in NG108-15 cells co-cultured with C2C12 myotubes. These results suggest that motor neurons may be regulating their own supply of GDNF secreted by skeletal muscle and that activation of AChRs may be involved in this process.

Bilateral asymmetric mucoceles of the paranasal sinuses: a first case report.

Bilateral paranasal sinus mucoceles are rare. To date, only 5 cases have been reported in the English-language literature. All were bilaterally symmetrical. We present a patient with bilateral asymmetric mucoceles. This patient had a symptomatic mucocele of the right ethmoid sinus with orbital extension and an asymptomatic mucocele involving the left maxillary sinus with retroorbital extension. The latter was an incidental finding on radiologic evaluation. This is the first case report of bilateral mucoceles with asymmetric involvement of the paranasal sinuses.