Endoscopic transantral and transnasal repair of orbital floor fracture with the ballooning technique, and classification and characterization of orbital floor fractures.

BACKGROUND: The level of difficulty during an endoscopic approach for an inferior orbital fracture depends on the fracture pattern and the presence of a ruptured membrane (orbital periosteum and sinus mucosa). The purpose of our study was to examine fracture patterns according to age group and to determine the relationship between the type of fracture and the type of membrane injury. METHODS: We reviewed the records of 30 patients who, from 2006 to 2010, underwent endoscopic transantral and transnasal approach with a balloon catheter technique to repair orbital floor fracture. The procedure was done through middle or inferior meatal antrostomy and two small antrostomies made in the anterior wall of the maxillary sinus by using an endoscope and specially designed curved dissectors. RESULTS: There were 3 linear, 20 trapdoor-type and 7 blowout fractures. There was a tendency toward a higher incidence of linear fractures at younger ages and of blowout fractures in older patients. All linear fractures had rupture of both membranes, whereas both membranes were intact in 15 of the 20 patients with trapdoor fractures. Among blowout fractures, there was no membrane rupture in five and both membranes were ruptured in two patients. No patient reported diplopia after fracture repair. CONCLUSIONS: Rupture of the periosteum, which makes visualization and reduction of orbital tissue difficult for the surgeon during endoscopic repair of the orbital floor fracture, was observed in 3 of 3 linear fractures and 5 of 20 trapdoor fractures. We found that linear fractures were more common in pediatric patients. Care of pediatric orbital floor fracture requires particular caution.

Identification of Onodi cell and new classification of sphenoid sinus for endoscopic sinus surgery.

BACKGROUND: There is no effective classification method for the opening of the sphenoid sinus. The objective of this study was to examine the effectiveness of identification of the Onodi cell and classification of the sphenoid sinus using sagittal computed tomography (CT) for sphenoidotomy. METHODS: CT images of the sinuses of surgical patients (n = 261; 522 sides) were studied. Using sagittal CT, the relationships between the lateral side of the anterior wall of the sphenoid sinus and the optic nerve, and between the middle of the anterior wall of the sphenoid sinus and the skull base or pituitary gland were studied. Images were classified as demonstrating skull base (without the Onodi cell), optic canal, sella, or infra-sella (all with the Onodi cell) type. RESULTS: Two hundred and fifty-eight sides (49.2%) were of the skull-base type, 181 (34.7%) were of the optic-canal type, 58 (11.1%) were of the sella type, and 26 (5.0%) were of the infra-sella type; ie, the Onodi cell was present in 50.8% of sides. The width of the anterior wall of the sphenoid sinus became narrower as it shifted from the skull-base type to the infra-sella type. CONCLUSION: Classification of the anterior wall of the sphenoid sinus based on the Onodi cell allows 3-dimensional assessment of the shape of the sphenoid sinus. We believe that the sphenoid sinus can be opened safely by full preoperative assessment of the anterior wall type, the position of the superior turbinate, and the position of the ostium of the sphenoid sinus.

[A 5-year study of patients with neck lymphadenopathy].

The purpose of this study was to investigate neck lymphadenopathy patients in our hospital, and to investigate items requiring attention on the occasion of examination of these patients. In this study, 134 patients with neck lymphadenopathy in the five years from April 2005 to March 2010 were included. The kind of diseases, the period of suffering (the period from onset to consultation), relationship with pain, radiological examination, fine needle aspiration cytology and lymph node biopsy findings were examined. Of 134 patients, the disease was inflammatory in 109 patients (81.3%) and malignant in 25 patients (18.7%). The suffering period was longer in the malignant group than in the inflammatory group. Furthermore, the inflammatory group had more patients with neck lymph node pain than the malignant group, and the group with the short suffering period had more patients with neck lymph node pain than that with the long suffering period. Fine needle aspiration cytology was performed in 36 patients (26.9%), and finally, all of the seven patients with class III were diagnosed as having malignant disease. A neck lymph node biopsy was performed in 38 patients (28.4%), and four of 38 patients were diagnosed as having metastatic carcinoma. Two patients in the inflammatory group and two patients in the malignant group took more than 90 days to reach a definite diagnosis. Many kind of diseases cause neck lymphadenopathy, and, therefore, it is important to perform a neck lymph node biopsy immediately, if it is difficult to establish a diagnosis.

[Evaluation of clinical features of antrochoanal polyps].

Current knowledge on the prevalence and clinical features of antrochoanal polyps (ACPs), benign lesions arising in the maxillary sinus and extending into the choana, is very limited in Japan. We prospectively evaluated prevalence and clinical features in 15 subjects with ACPs from among 728 undergoing endoscopic endonasal sinus surgery between April 2007 and March 2008, and prospectively enrolled in this study. The 15 subjects, who accounted for 2.1% of the total, had nasal obstruction, rhinorrhea, and postnasal drip. Symptoms significantly reduced postoperatively. Maxillary-sinus-origin ACP distribution was 40% from the maxillary sinus floor to the posterior wall, 26.7% from maxillary sinus floor, and 20% from the maxillary sinus floor to the internal wall. Postoperative recurrence was 13.3%. Endoscopic endonasal sinus surgery for ACPs was most effective for polyp is originating in the maxillary sinus determined carefully and excised as completely as possible, followed by appropriate postoperative treatment.

[Endoscopic sinus surgery complications a prospective multicenter study].

OBJECTIVE: Our objective was to determine the rate of complications in endoscopic sinus surgery (ESS) and associated risk factors. METHODS: We prospectively studied 1,382 subjects undergoing ESS for rhinosinusitis and cystic sinus disease at 16 hospitals during 2007 and 2008. Surgeons provided information on peri-and postoperative complication occurrence. RESULT: Results of complications were seen in 80 subjects (5.8%), the most frequent was perioperative lamina papyracea injury. Analysis showed the complication rate to be linked to gender, and anesthesia type, but not the grade of surgeon. CONCLUSIONS: While care should be taken to avoid them, complications should be identified and treated in a timely and accurate manner.

Risk factors for complications of endoscopic sinus surgery for chronic rhinosinusitis.

BACKGROUND: Patients undergoing endoscopic sinus surgery (ESS) are at risk of complications because of the close proximity of the sinuses to the orbit and anterior skull base. The aim of this study was to evaluate the complications of ESS and to identify patient characteristics that were risk factors for the complications. METHODS: We conducted a prospective study of 706 patients who underwent ESS for chronic rhinosinusitis. Patients completed preoperative examinations that included computed tomography, endoscopic observation for nasal polyps, and tests for comorbidities including asthma and vascular disease. Perioperative complications were evaluated based on information provided by the surgeons. Multivariate analysis was performed to identify patient characteristics that were risk factors for complications. RESULTS: Overall, perioperative complications occurred in 41 patients (5.8%). A major complication, cerebrospinal fluid leakage, occurred in one patient (0.1%). Minor complications occurred in 40 patients (5.7%), with the most common being intraoperative hemorrhage (n = 18). Multivariate analysis indicated that presence of asthma and the total polyp score correlated significantly with the occurrence of complications. CONCLUSION: The risk factors for perioperative complications were asthma and the polyp score. We conclude that the surgeon should confirm whether the patient has lower airway disease, especially asthma, before operating. The surgeon should also determine the grade of nasal polyps.

[Blowout fracture repositioning by fenestration].

Blowout fracture repositioning is done, surgically, infraorbitally, transnasally following endoscopic sinus surgery, and transantrally. Repositioning using fenestration is minimally invasive compared to the conventional Caldwell Luc procedure. Subjects involved 21 cases, and was under the medical treatment. I estimated the treatment results as the improvement degree of subjective symptoms at the improvement degree of the visible symptom views that used a Hess chart. As a result, the fenestration method showed good improvement degree, and it was not the thing which had the big vice-damage. Fenestration thus is useful in blowout fracture repositioning.

[Treatment of sleep apnea syndrome in a Down syndrome patient with behavioral problems by noninvasive positive pressure ventilation: a successful case report].

The use of noninvasive positive pressure ventilation (NPPV) is increasingly accepted as a treatment of respiratory problems in patients with neuromuscular disease. However, its use in mentally retarded and un-cooperative patients has not been reported. We report here the evaluation and treatment of sleep apnea in a Down syndrome patient. After recovering from a life threatening respiratory failure the patient had persistent sleep apnea syndrome. Limited examinations disclosed that he had two types of apnea; obstructive and central type apnea. Our treatment was a diet with intake restricted up to 1,000 kcal per day for the obstructive apnea, and NPPV with low dosage of oxygen for the obstructive and central apnea. With these treatments in one year's hospitalization, his quality of life was significantly improved. He has continued the treatment in the outpatient department and enjoys a better quality of life both at home and in the community. The successful treatment of this case may become an example of the more extensive use of NPPV for such respiratory problems in handicapped children and adults with behavioral problems.

[Effects of ESS on sinobronchial syndrome].

Sinobronchial syndrome (SBS) is characterized by chronic sinusitis with chronic infection of the bronchus. Chronic bronchitis, bronchiectasis and diffuse panbronchiolitis are also examples of complicating lower airway disease. In Japan, the surgical treatment of sinusitis is not considered to improve the lower airway diseases. Most published reports describe the Caldwell-Luc method. However ESS (Endoscopic Sinus Surgery) can heal sinusitis while maintaining the morphology and function of the paranasal sinus. In addition, its surgical results are satisfactory. This report describes the improvement of patients with SBS who underwent ESS. Twelve patients with sinobronchial syndrome who underwent ESS at our department between 1989 and 1993 were enrolled in the study. Subjective improvement in sinusitis and the lower airway diseases were evaluated using a questionnaire. Objective improvements in sinusitis were evaluated using endoscopic findings of the ethmoid sinuses, while objective improvements in the lower airway diseases were evaluated by measuring the vital capacity and FEV 1.0%. These examinations were performed one year after the operation; the results of long-term follow-up examinations performed more than 6 years after the operation were also studied. In all of the patients, subjective nasal symptoms and objective endoscopic findings were satisfactory, with improvement rates of 91.7% and 83.3%, respectively. Regarding the lower airway symptoms, all the patients subjectively rated the symptoms as having improved, and an improvement in the FEV 1.0% was improved in all of the cases. In the present study, the lower airway symptoms improved after ESS. ESS enables the paranasal sinuses to be treated while maintaining the morphology of the paranasal sinus. Consequently, surgical results are better. The improvement of chronic sinusitis reduces the direct inflow of postnasal drippings into the bronchus. Restoring the normal functions of the nasal sinus defends the lower airway by warning, and humidifying the inspiratory air and removing dusts; these functions are though to have a favorable effect on the lower airway.

[Allergic fungal sinusitis].

Allergic fungal sinusitis (AFS) is considered an allergic inflammation against fungus, and has been reported to be refractory, with very high recurrence. In Europe and the United States, AFS incidence is reported from 4% to 7% in patients with chronic sinusitis undergoing endoscopic sinus surgery (ESS). In Japan, however, only 5 patients, including ours have been reported, making AFS very rare in Japan. We prospectively studied the incidence, pathogenesis and diagnosis of AFS in Japan among 102 patients with chronic sinusitis who underwent ESS. Four cases (3.9%) were diagnosed with AFS based on the criteria of Bent and Kuhn. This incidence is slightly lower than that reported in Europe and the United States. We report the diagnosis, treatment, and course in 4 AFS patients. Of these, an allergen provocation test against detected fungus was conducted in 2 from whom informed consent was obtained. In the immediate phase, positive reactions were observed. Immunoglobulin E (IgE) antibody-mediated type I allergy may be involved in the pathogenesis of AFS.