How we do it: mini posterior septal artery flap for coverage after transphenoidal approaches.

We propose a novel posterior nasal flap for use in endoscopic approaches to the sella and parasellar region that involve resection of the sphenoid face and a posterior nasal septectomy. It involves elevation of the mucosa of the posterior septum and sphenoid face with preservation of the angiosome based on the posterior septal artery. This flap has the advantages of maximal mucosal preservation in order to optimize postoperative healing and has been demonstrated to permit future elevation of a complete naso-septal flap for reconstruction of anterior skull base defects. An illustration of the technique is provided.

Predicting the site of attachment of sinonasal inverted papilloma.

STATEMENT OF PROBLEM: Sinonasal inverted papilloma is a benign, epithelial neoplasm, which has a propensity for malignant transformation and recurrence. The evolution of endoscopic trans-nasal surgery has facilitated less destructive and, more functionally and cosmetically acceptable approaches to this tumour. Recurrence rates have been shown to be more favourable than after traditional external approaches. Precise surgery is enhanced by pre-operative localisation of the site of tumour attachment. The aim of this study was to examine, in a prospective fashion, the predictive value of osteitis on the pre-operative CT scan of the paranasal sinuses at correctly identifying the site of attachment of sinonasal inverted papilloma. METHOD OF STUDY: Pre-operative CT scans of the paranasal sinuses in 24 patients with histology-proven sinonasal inverted papilloma were examined for osteitis, allowing a prediction of the site of attachment. Coronal reformats of thin-cut (1mm) axial CT scans were evaluated. Intra-operatively, the actual site of tumour attachment was established. A correlation between the predicted and actual site of tumour attachment was calculated. MAIN RESULT: The predictive value of the osteitis sign was 95%. PRINCIPAL CONCLUSION: Pre-operative identification of osteitis can be used in 95% of cases to accurately predict the intra-operative site of attachment of sinonasal inverted papilloma.

Squeeze bottle versus saline spray after endoscopic sinus surgery for chronic rhinosinusitis: a pilot multicentre trial.

BACKGROUND: There is a need for controlled trials to guide the perioperative management of patients undergoing endoscopic sinus surgery (ESS). The authors performed a pilot multicenter trial to compare two types of saline delivery devices in this population. METHODS: Patients were randomized to high volume saline irrigation with a squeeze bottle and low volume saline spray after ESS in patients with chronic rhinosinusitis (CRS). Surgeons were blinded to treatment, and one-month postoperative scores for sinonasal outcomes [Sinonasal Outcome Test-22 (SNOT-22)] scale, nasal and sinus symptom score (NSS), and perioperative sinus endoscopy (POSE) scale were compared with preoperative scores. RESULTS: Nine centers provided data for 86 patients. All three outcomes measures improved significantly for both groups. Saline spray: SNOT-22 48.8 versus. 23.7, treatment effect 25.1 (95% confidence interval [CI], 17.9-32.2), POSE 21.1 versus. 8.4, treatment effect 12.7 (95% CI, 9.2-16.1), and NSS 8.2 versus 5.0, treatment effect 3.1 (95% CI, 1.4-4.9) pre- and postoperatively, respectively (all p < 0.0001). Squeeze bottle: SNOT-22 49.5 versus 23.6, treatment effect 25.9 (95% CI, 20.3-31.6), POSE 18.6 versus 9.2, treatment effect 9.3, (95% CI 6.7-12.0), and NSS 9.0 versus 5.7, treatment effect 3.3 (95% CI, 2.3-4.3) pre- and postoperatively, respectively (all p < 0.0001). Analysis of variance did not identify a difference between the two treatment groups. Subgroup analysis based on preoperative disease severity did not change the nonassociation of saline bottle with outcome measures. Post hoc sample size calculation determined that 176 patients is required to detect an 8.9-point difference in SNOT-22 scores. CONCLUSION: In this pilot multicenter trial examining patients with chronic rhinosinusitis undergoing ESS, both squeeze bottle and saline spray showed significant improvement in SNOT-22, POSE, and NSS scores at one-month postoperatively. Because the study was nonpowered, we cannot rule out a potential difference between the two treatment groups.

Topical 0.050% betamethasone dipropionate. Pharmacokinetic and pharmacodynamic dose-response studies in humans.

BACKGROUND AND DESIGN: Effective topical drug therapy requires drug delivery into the skin to produce the desired pharmacodynamic response. For topical corticosteroids, the visual skin-blanching assay has been used to rank the potency of the corticosteroids and their overall efficacy. While vehicles have been shown to influence the resulting blanching response, the dose of drug applied has not always produced proportional differences in the blanching assay. The mechanism of the nonproportional pharmacodynamic response to the corticosteroid dose is unclear. We describe four methods for assessing the dose-response relationship of topical betamethasone dipropionate on the ventral forearm of six human subjects: duration, concentration, film thickness, and surface area. Drug uptake analysis in human stratum corneum and the resulting pharmacodynamic response, measured visually and with a chromameter, were performed with each method to quantify the dose-response relationship. RESULTS: Only the concentration and duration methods demonstrated an increase in mean drug uptake with increasing dose. The maximal mean pharmacodynamic response reflected the mean drug uptake with all four methods. Application conditions for maximal pharmacodynamic activity of topical betamethasone dipropionate in the skin include short duration of treatment (< or = 2 hours), a lower concentration than commercially marketed, and thin film thicknesses (1 to 5 microns). CONCLUSION: A dose response can be produced by increasing the drug concentration or the duration of application time. Achievement of steady-state betamethasone dipropionate uptake into the stratum corneum was not commensurate with the maximal pharmacodynamic response. Very small amounts of this potent corticosteroid within the skin appear to maximize the receptor response to drug.

Schistosomiasis of the female genital tract. A histopathological study of 176 cases from Malawi.

The histopathology of 176 cases of gynaecological schistosomiasis reported from Malawi during the period 1976-80 was reviewed. Schistosomal infection was found throughout the genital tract, with 60% of cases involving the cervix. The dominant tissue reactions to ova were categorized into five histopathological groups A-E and for each site the relationship between histopathological and clinical features was explored. No evidence was found linking schistosomiasis with cancer of the genital tract. Schistosomiasis was a significant cause of gynaecological morbidity, particularly when infection involved the lower genital tract; however in a proportion of cases ova were found coincidentally in other lesions or normal tissues, and were not apparently causally linked with symptoms. The findings are discussed in relation to previous studies of gynaecological schistosomiasis.

Pasteurella multocida infection of a total hip arthroplasty following cat scratch.

Pasteurella multocida is a well recognized cause of sepsis following animal contact particularly bites and scratches. Spread to prosthetic joints may occur particularly in immunocompromised patients. Immunocompromised patients with prosthetic joints should be warned that animals are potential sources of serious infection and urgent medical advice should be sought if bitten or scratched.

Early-onset neonatal pneumococcal sepsis in siblings.

The case of a woman who in two successive pregnancies produced premature infants affected by early-onset Streptococcus pneumoniae type 8 sepsis is described. Low maternal levels of pneumococcal IgG antibodies were demonstrated after the second delivery, and vaccination with 'Pneumovax' produced a rise in antibody levels. Attention is drawn to the similarity between early-onset pneumococcal neonatal sepsis and group B streptococcal sepsis. Mothers of infants affected by early-onset pneumococcal sepsis who have low pneumococcal antibody levels run the risk of subsequent babies being similarly affected and vaccination should be considered to prevent recurrence.

Objective and subjective outcomes in surgery for chronic sinusitis.

Endoscopic and radiological findings in patients with chronic sinusitis do not always correlate with symptoms. Studies suggest that postoperative endoscopic examination of the sinonasal cavity provides prognostic information regarding the potential for future episodes of sinusitis and the need for revision surgery. It is recommended that findings on nasal endoscopy be included in future outcomes studies on sinusitis.

Th-2 type cytokine receptors in allergic rhinitis and in response to topical steroids.

OBJECTIVES: Th-2 type cytokine production (interleukin-4 [IL-4] and interleukin-5 [IL-5]) has been demonstrated to play a significant role in the pathophysiology of allergic rhinitis (AR), and the treatment of AR with topical corticosteroids has been shown to reduce the expression of Th-2 type cytokines in vivo. However, the contribution and expression of Th-2 type cytokine receptors in AR and their response to corticosteroid treatment remain to be clarified. Objectives of the current study are 1. To examine the expression of the cytokine IL-4 and IL-5 receptors (IL-4R and IL-5R) in a nasal allergen challenge model and to contrast this with the expression of the receptor for the Th-1 type cytokine, interferon-gamma receptor (IFN-gammaR), and 2. to examine the effects of pretreatment with topical corticosteroid before allergen challenge on the expression of these same receptors. STUDY DESIGN: Randomized prospective study involving 14 ragweed-allergic subjects evenly divided between placebo and corticosteroid pretreatment. METHODS: Immunocytochemistry (alkaline phosphatase-antialkaline phosphatase labeling [APAAP] technique) was used to stain nasal biopsy specimens before and after allergen challenge. Antibodies used included anti-CD3, CD4, CD8, MBP, IL-4R, IL-5R, and IFN-gammaR. RESULTS: Following allergen challenge, we observed a significant increase in the Th-2 type cytokine receptors (IL-4R and IL-5R; P < .05), as well as a significant decrease in the expression of the Th-1 type cytokine receptor (IFN-gammaR; P < .05). Pretreatment with topical corticosteroids before nasal allergen challenge resulted in decreased expression of IL-4R (P < .05) and IL-5R (P < .05) and increased expression of IFN-gammaR (P <.05). Further, IL-4R and IL-5R expression correlated with eosinophil infiltration in the tissues. CONCLUSIONS: We have demonstrated that in AR, cytokine receptors for IL-4, IL-5, and IFN-gamma follow a similar pattern to their ligands. In addition, pretreatment with topical corticosteroids was shown to alter the cytokine receptor expression pattern from a Th-2 profile more toward a Th-1 profile.

Th-2 type cytokine receptors in allergic rhinitis and in response to topical steroids.

OBJECTIVES: Th-2 type cytokine production (Interleukin-4 [IL-4] and interleukin-5 [IL5]) has been demonstrated to play a significant role in the pathophysiology of allergic rhinitis (AR), and the treatment of AR with topical corticosteroids has been shown to reduce the expression of Th-2 type cytokines in vivo. However, the contribution and expression of Th-2 type cytokine receptors in AR and their response to corticosteroid treatment remain to be clarified. Objectives of the current study are 1. To examine the expression of the cytokine IL-4 and IL-5 receptors (IL-4R and IL-5R) in a nasal allergen challenge model and to contrast this with the expression of the receptor for the Th-1 type cytokine, interferon-gamma receptor (IFN-gammaR), and 2. to examine the effects of pretreatment with topical corticosteroid before allergen challenge on the expression of these same receptors. STUDY DESIGN: Randomized prospective study involving 14 ragweed-allergic subjects evenly divided between placebo and corticosteroid pretreatment. METHODS: Immunocytochemistry (alkaline phosphatase-antialkaline phosphatase labeling [APAAP] technique) was used to stain nasal biopsy specimens before and after allergen challenge. Antibodies used included anti-CD3, CD4, CD8, major basic protein (MBP), IL-4R, IL-5R, and IFN-gammaR. RESULTS: Following allergen challenge, we observed a significant increase in the Th-2 type cytokine receptors (IL-4R and IL-5R; P<.05), as well as a significant decrease in the expression of the Th-1 type cytokine receptor (IFN-gammaR; P<.05). Pretreatment with topical corticosteroids before nasal allergen challenge resulted in decreased expression of IL-4R (P<.05) and IL-5R (P<.05) and increased expression of IFN-gammaR (P<.05). Further, IL-4R and IL-5R expression correlated with eosinophil infiltration in the tissues. CONCLUSIONS: We have demonstrated that in AR, cytokine receptors for IL-4, IL-5, and IFN-gamma follow a similar pattern to their ligands. In addition, pretreatment with topical corticosteroids was shown to alter the cytokine receptor expression pattern from a Th-2 profile more toward a Th-1 profile.

Increased expression of major basic protein (MBP) and interleukin-5(IL-5) in middle ear biopsy specimens from atopic patients with persistent otitis media with effusion.

BACKGROUND: Molecular biologic evidence to support an etiologic role for allergy in the pathogenesis of persistent otitis media with effusion (OME) is lacking. OBJECTIVE: The goal of this article was to document expression of allergy-associated Th-2-type cytokines and inflammatory cells in the middle ear mucosa of children with persistent OME. METHODS: With immunocytochemistry (CD3, major basic protein) and in situ hybridization (interleukin-5 mRNA), middle ear biopsy specimens from 7 children with persistent OME were stained. Nonatopic stapedectomy patients with no history of otitis media served as controls (n = 7). RESULTS: There was a statistically significant (P< 0.05) difference in expression of CD3, major basic protein, and interleukin-5 between experimental and control subjects. All 8 OME patients proved to be atopic by ELISA testing. CONCLUSIONS: Type I allergy involving a Th-2-type cytokine and cellular profile may be a contributing factor in the persistence of OME in atopic children. SIGNIFICANCE: The middle ear may serve as a target organ for allergic inflammation, suggesting that appropriate allergy management may be a useful adjunct to the management of OME.

Interleukin-4, interleukin-5, and granulocyte-macrophage colony-stimulating factor receptor expression in chronic sinusitis and response to topical steroids.

Chronic sinusitis and its associated eosinophilic infiltrate are believed to be mediated, at least in part, by the upregulation of Th-2 cytokines, including interleukin-4, interleukin-5, and granulocyte-macrophage colony-stimulating factor (GM-CSF). Interleukin-4 is involved in IgE production and in eosinophil recruitment through upregulation of vascular cell adhesion molecule-1. Interleukin-5 and GM-CSF are involved in eosinophil growth and survival. The aim of this study was to investigate the expression of receptors for these cytokines in the sinus mucosa of subjects with chronic sinusitis. Using the technique of in situ hybridization to detect specific cytokine receptor messenger RNA, we studied the sinus mucosa of subjects with nonallergic chronic sinusitis, subjects with allergic chronic sinusitis, subjects with allergic chronic sinusitis treated with topical steroids, and normal controls. Our data demonstrate higher expression of interleukin-4 receptor in subjects with allergic chronic sinusitis than in controls (p < 0.001) and higher expression of interleukin-5 receptor in both subjects with nonallergic chronic sinusitis and subjects with allergic chronic sinusitis than in controls (p < 0.001, p < 0.001). The expression of interleukin-4 receptor and interleukin-5 receptor was higher in subjects with allergic chronic sinusitis than in subjects with nonallergic chronic sinusitis (p < 0.001). GM-CSF receptor expression was also found to be higher in subjects with allergic chronic sinusitis and subjects with nonallergic chronic sinusitis than in controls (p < 0.001, p < 0.001). In contrast to interleukin-4 receptor and interleukin-5 receptor, however, expression of GM-CSF receptor was higher in subjects with nonallergic chronic sinusitis than in subjects with allergic chronic sinusitis (p < 0.001). In subjects with allergic chronic sinusitis treated with topical corticosteroids, the expression of interleukin-4 receptor and interleukin-5 receptor messenger RNA levels was significantly lower than levels in patients with allergic chronic sinusitis who were not taking topical steroids (p < 0.001, p < 0.001). Steroid treatment had no effect on GM-CSF receptor messenger RNA expression. In conclusion, our data support a role for Th-2 cytokine receptors in the pathophysiology of chronic sinusitis. Further, our data lend support to the theory that differential activation of distinct cytokine pathways mediates inflammation in chronic sinusitis depending on whether there is associated allergy. Finally, treatment with topical corticosteroids has been demonstrated in chronic sinusitis to downregulate receptors for interleukin-4 and interleukin-5.

Laterally hypertrophic adenoids as a contributing factor in otitis media.

Adenoidectomy has been demonstrated in randomized controlled studies to be effective in the prevention of otitis media with effusion (OME). Despite an apparent lack of correlation between adenoid size and outcome, it has been suggested that the role of adenoid tissue in the pathophysiology of OME relates either to obstruction of the Eustachian tube (ET) with impairment of its function, or to adenoid tissue serving as a reservoir of infection. The aim of this study was to further delineate the relationship between adenoid hypertrophy and OME. This prospective survey was performed in an ambulatory care setting of a tertiary care pediatric hospital, where data was collected on 273 consecutive adenoidectomy patients. At the time of surgery, adenoid position in relation to the ET orifice was recorded as well as concurrent procedures performed (e.g. pressure equalization tubes; PET). Sixty percent of patients undergoing simultaneous PET insertion were found to have laterally hypertrophic adenoid tissue encroaching upon the ET orifice versus only 22% for those undergoing adenoidectomy alone. Thus, a strong correlation was found to exist between OME, requiring the placement of PET and lateral adenoids abutting the torus tubarius (chi2 = 39.12; P < 0.001). The clinical relevance of this finding is that it may allow the prediction of children with OME, who will benefit most from undergoing adenoidectomy. Patients with OME requiring PET insertion, who are found to have lateral adenoid hypertrophy encroaching upon the ET orifice, could be selected for adenoidectomy, thus allowing a more judicious application of this surgical procedure in the setting of OME.

The bulla ethmoidalis: lamella or a true cell?

BACKGROUND: The anterior ethmoidal region, including the bulla ethmoidalis, is the most common area addressed during functional endoscopic sinus surgery. Therefore, a detailed understanding of the bulla is essential for safe and effective surgery. HYPOTHESIS: Based on a review of historical articles on sinus anatomy and review of the current understanding of sinonasal embryology, it is suggested that the ethmoidal bulla is a "lamella" structure rather than a "cell," as it is widely accepted to be. OBJECTIVE: To analyze the anatomic conformation and nature of the ethmoidal bulla. METHODS: Detailed gross anatomic sagittal dissection of 14 sinonasal complexes with special attention to the ethmoidal bulla and surrounding structures and pneumatization tracts. RESULTS: The ethmoidal bulla consisted of a distinct bony lamella in all cases. The degree of development and pneumatization was variable, ranging from a rudimentary torus to a relatively well-pneumatized "bulla"-like structure. A pneumatization tract originating from the retrobullar recess was present in all specimens. This pneumatization excavated into the lamella, creating the bulla-like appearance as viewed from the middle meatus. However, the bulla was not a discrete individual ethmoid cell as it did not have a complete or discrete posterior bony wall. Rather, the posterior wall of this pneumatization tract was formed by the basal lamella. CONCLUSION: The ethmoidal bulla lacks a distinct posterior wall and therefore is not a separate cell but rather a bony lamella with an air space behind it. From an anatomic perspective, bulla is perhaps not the best term for this structure.

Ablative adenoidectomy: a new technique using simultaneous liquefaction/aspiration.

OBJECTIVE: This study was performed to critically evaluate a new cautery technique for adenoidectomy that combines indirect visualization with complete hemostasis, ultimately permitting the surgeon to tailor the procedure to the patient's specific needs. DESIGN: This prospective study of 138 consecutive adenoidectomy patients of the senior author was carried out at the Montreal Children's Hospital over 17 months. Concurrent adenoidectomy patients of another senior otolaryngologist in our institution as well as cases of the senior author using the conventional cold curettage technique served as controls. METHOD: Data were collected preoperatively with respect to indication for surgery and radiologic findings. Operative findings including duration of surgery, concurrent procedures, position of adenoid hypertrophy, and blood loss were also recorded. Postoperative complications such as hemorrhage, infection, dehydration, as well as the incidence of velopharyngeal insufficiency and nasopharyngeal stenosis were also recorded up to 1 year from the date of surgery. The operative technique involves indirect visualization of the nasopharynx with a laryngeal mirror combined with cautery-liquefaction and suction ablation of the adenoid tissue. RESULTS: Our results demonstrate a significant reduction in blood loss as well as a reduction in operative time. There was a low incidence of postoperative infection, no patients required a return to the operating room for hemostasis, and there were no cases of recurrent adenoid hypertrophy. There was no detectable difference in the incidence of postoperative complications. CONCLUSION: We conclude that this technique is safe and time-efficient, with the advantages of excellent visualization and essentially no operative blood loss.

One-year outcome analysis of functional endoscopic sinus surgery for chronic sinusitis.

OBJECTIVE: This study was conducted to assess treatment results in patients undergoing functional endoscopic sinus surgery for chronic sinusitis, with evaluation of prognostic indicators of success and failure. METHOD: The study included 393 patients who underwent endoscopic sinus surgery for chronic sinusitis over a 4-year period. The diagnosis of chronic sinusitis was based on ongoing symptomatology for greater than 3 months and the presence of mucosal disease on computerized tomography (CT). A retrospective analysis was done looking at patient data, presenting symptoms, CT findings, operative reports, pathology reports, and outcome at 6- and 12-month follow-up. The prognostic significance of selected factors was evaluated using chi-square analysis. RESULTS: A positive history for asthma, allergy, and ASA triad was present in 29.5%, 34.6%, and 10.9% of patients, respectively. Previous sinus surgery was done in 31.9%, and 15.7% of patients were smokers. The most common presenting complaint was nasal congestion/obstruction, followed by facial pain/headaches and olfactory disturbance. A positive outcome was achieved in 80.5% of patients at 6 months and in 69.7% at 12-month follow-up. Revision surgery within a year was needed in 4.1% of patients. Factors affecting outcome included asthma, smoking, polyposis, previous surgery, and pansinusitis. CONCLUSIONS: Extent of disease, as reflected by polyposis, pansinusitis, and premorbid history, is the most important determinant of outcome. Concomitant changes in ciliary motility secondary to asthma or smoking further impede surgical outcome. Future studies focusing on the disease process of chronic sinusitis are needed.

Endoscopic orbital decompression with preservation of an inferomedial bony strut: minimization of postoperative diplopia.

With the increasing sophistication and safety of endoscopic orbital decompression, the technique is seen by many as an attractive and less morbid alternative to traditional open techniques. This rationale also makes the procedure more acceptable for individuals considering decompression for cosmetic reasons. As a result, complications such as postoperative diplopia assume greater significance. Preservation of an inferomedial bony strut has been postulated to reduce the incidence of postoperative diplopia in transconjunctival, but not endoscopic, orbital decompression for dysthyroid ophthalmopathy. We present a consecutive series of 11 subjects (21 eyes) who underwent transnasal endoscopic medial and inferior decompression of the orbits bilaterally. All patient charts were reviewed in a retrospective fashion and ophthalmologic, surgical, and cosmetic data were recorded, with callback of patients with incomplete data sets. All cases were performed under general anaesthesia. Preservation of the strut was possible in 15 of 21 eyes. Visual acuity was preserved or improved in all 21 eyes. Average ocular recession based on Hertel measurements was 3.6 mm and there were no surgical complications. New-onset or worsening diplopia was noted postoperatively in 2 of 11 subjects. However, in patients where both struts were preserved, there was zero incidence of postoperative diplopia (0/6). These results indicate that preservation of an inferomedial bony strut is not only technically feasible but also does not compromise the adequacy of decompression. The results also suggest that preservation of the inferomedial bony strut during endoscopic orbital decompression can reduce the incidence of postoperative diplopia.