The role of local steroid injection for nasal polyposis.

Sinonasal polyps affect a small but significant percentage of patients with chronic sinusitis. Treatments vary and range from oral and topical medical treatments to surgical removal. Corticosteroids typically have been regarded as the gold standard medical treatment for sinonasal polyps. Delivery of steroids is traditionally via oral or topical means. Over the years, otolaryngologists have also found that intrapolyp injection of corticosteroids is an effective means to treat some patients with sinonasal polyps. This article reviews the prevalence, pathophysiology, and medical treatment options for sinonasal polyps. Focused attention is paid to treatment with steroid injections, including a review of its associated risks and benefits.

The ethmo-frontal angle: a new anatomic and radiologic landmark for use in sinus surgery.

OBJECTIVE: To identify anatomic and radiologic landmarks to assist with frontal sinus surgery. STUDY DESIGN: Retrospective review. SUBJECTS AND METHODS: Sinus CT scans of 50 patients were evaluated with respect to a new radiologic and anatomic landmark, the ethmo-frontal angle (EFA). RESULTS: Right-sided EFA ranged from 135 to 171 degrees. Left-sided EFA ranged from 136 to 167 degrees. Measurements of both sides displayed a normal distribution. When right and left sides within individuals were compared, there was no correlation to indicate a high degree of variation between any particular patient's right and left side EFA. CONCLUSION: The EFA is a new landmark to assist otolaryngologists during surgery on and around the frontal sinus. Normal values for this angle have been presented. Surgeons should be aware that asymmetry in a patient's EFA is common, and each side should be examined individually.

Balloon sinuplasty for the surgical management of immunocompromised and critically ill patients with acute rhinosinusitis.

OBJECTIVE: The purpose of this study was to review use of balloon sinuplasty for surgical treatment in critically ill patients with acute sinusitis. STUDY DESIGN: Case series with chart review. SUBJECTS AND METHODS: Patients who underwent balloon sinuplasty between October 2007 and March 2008 were identified. Medical records of the subset of patients who were immunocompromised or otherwise critically ill were analyzed. RESULTS: Thirty-one patients underwent balloon sinuplasty at our institution between October 2007 and March 2008. We identified five critically ill patients with sinus disease within this group. Patient ages ranged from 15 to 51 years with no sex preponderance. All patients had focal findings on a sinus CT scan. In all cases, purulent drainage was noted intraoperatively. All patients returned to baseline health meeting discharge criteria after treatment. CONCLUSION: Balloon sinuplasty represents a potentially less invasive surgical option than standard Functional Endoscopic Sinus Surgery (FESS) and should be considered in the treatment of critically ill or immunocompromised patients.

Revisiting the interpretation of positive sinus CT findings: a radiological and symptom-based review.

OBJECTIVE: It is widely believed that a high percentage of normal, healthy patients without sinusitis symptoms have abnormal findings on sinus CT. Experiences of the authors of this study suggest otherwise. STUDY DESIGN: Cross-sectional survey. SUBJECTS AND METHODS: Head/sinus CT scans of 50 consecutive patients from each of three study groups were reviewed. Group 1 consisted of patients without any sinus symptoms. Group 2 consisted of patients with acute headache symptoms. Group 3 consisted of patients with complaints consistent with chronic sinusitis. CT scans were evaluated with the Lund-Mackay scoring system. RESULTS: In the asymptomatic patient group (group 1), six (3%) patients had positive sinus CT scan findings, compared with 11 (5.5%) in the acutely symptomatic group (group 2), and 32 (64%) in the chronically symptomatic group (group 3). In the chronically symptomatic group (group 3), 64 percent of patients were allergic compared with 18% of the acute headache group (group 2) and 8 percent of the asymptomatic patient group (group 1). CONCLUSION: Results of this study suggest that symptomatic sinus patients are much more likely to have positive sinus CT scan findings than asymptomatic patients. Conversely, normal healthy patients should not be expected to have abnormal sinus CT scans.

Endoscopic localization of the anterior and posterior ethmoid arteries.

OBJECTIVES: Understanding the endoscopic locations of the anterior and posterior ethmoid arteries is important during endoscopic sinus or endoscopic skull base procedures so that these arteries can be avoided. Therefore, the objective of this study was to define the endoscopic locations of the ethmoid arteries. METHODS: Twenty-four cadaver heads were used to identify the endoscopic location of the ethmoid arteries via an external incision. An image guidance system was used to record the locations of these arteries. The anterior ethmoid artery was referenced to the axilla of the middle turbinate, and the posterior ethmoid artery to the anterior wall of the sphenoid sinus. The closest lamella to these arteries was identified. RESULTS: Forty-eight nasal cavities were dissected. The mean distance from the axilla to the anterior ethmoid artery was 17.5 mm. The anterior ethmoid artery was located immediately anterior to (31%), at (36%), or immediately posterior to (33%) the superior attachment of the basal lamella. The mean distance from the posterior ethmoid artery to the anterior ethmoid artery was 14.9 mm. The mean distance from the posterior ethmoid artery to the anterior wall of the sphenoid sinus was 8.1 mm. The posterior ethmoid artery was either anterior to (98%) or at (2%) the anterior face of the sphenoid sinus. CONCLUSIONS: Specific endoscopic anatomic relationships and measurements have been presented for the anterior and posterior ethmoid arteries.

Initial surgical treatment for chronic frontal sinusitis: a pilot study.

OBJECTIVES: The initial surgical treatment for chronic frontal sinusitis is not well defined. Our objective was to determine the effectiveness of anterior ethmoidectomy for chronic frontal sinusitis. METHODS: Patients with chronic frontal sinusitis who underwent anterior ethmoidectomy as initial surgical treatment were reviewed. Data were collected from computed tomography scans with use of the Lund-Mackay scale. Data on demographics, comorbidities, management, postoperative recovery, and follow-up were collected. RESULTS: Seventy-seven patients representing 121 diseased frontal sinuses met the inclusion criteria. The respiratory comorbidities were asthma alone (8.3%), asthma and polyps (6.6%), aspirin triad (5.8%), and cystic fibrosis (0.8%). Nineteen of 121 frontal sinuses (15.7%) belonged to smokers. Fourteen of 121 frontal sinuses (11.5%) exhibited postoperative evidence of disease. Of these 14 frontal sinuses, 10 (8.3%) underwent revision surgery. Frontal sinuses of patients with aspirin triad, with both nasal polyposis and asthma, or with inter-frontal sinus septal cells were more likely to fail Draf I surgery (p < .05). CONCLUSIONS: Anterior ethmoidectomy for drainage of frontal sinuses appears to be effective initial surgical treatment for chronic frontal sinusitis. Patients with aspirin triad, both asthma and polyposis, or inter-frontal sinus septal cells are more likely to fail this procedure.

Limits of endoscopic visualization and instrumentation in the frontal sinus.

BACKGROUND: Endoscopic limitations in the frontal sinus are poorly defined. We set out to define these limits. METHODS: Fifteen cadaveric heads underwent endoscopic frontal sinusotomies (Draf IIA, IIB, III). Areas of frontal sinus openings were calculated. Coordinates of the most distant points for instrumentation, visualization, and instrumentation with visualization in the frontal sinus were identified with the use of image guidance. RESULTS: Twenty-eight frontal sinuses were evaluated. The mean sinus opening areas were 47.5 mm2, 105.1 mm2, and 246.4 mm2 for Draf IIA, IIB, and III. Visualization exceeds instrumentation and visualized reach (P<0.05) regardless of different frontal sinusotomies. Anterior and lateral instrumentation and visualized reach increase as the frontal sinus opening increases (PIIB>IIA (P<0.04). There is no statistical difference for superior visualization, instrumentation, and visualized reach among various sinusotomies (P>0.05). CONCLUSIONS: Endoscopic visualization exceeds instrumentation and instrumentation exceeds visualized reach. Enlarging frontal sinus opening area increases instrumentation and visualization.

Intermediate crural overlay in rhinoplasty: a deprojection technique that shortens the medial leg of the tripod without lengthening the nose.

OBJECTIVE: To review the indications for, surgical techniques of, and results of intermediate crural overlay of the alar cartilages in rhinoplasty. DESIGN: Prospective study of patients undergoing intermediate crural overlay of the lower lateral cartilages. The setting was a facial plastic surgery private practice. Patients included 10 primary rhinoplasty patients and 1 revision rhinoplasty patient who underwent intermediate crural overlay of the lower lateral cartilages. The main outcome measures were postoperative photographs and patient records, which were reviewed for tip projection and rotation, preservation of the double break, bossae, and knuckling. RESULTS: Intermediate crural overlay decreased projection in all 11 patients and increased the nasolabial angle in 7 patients. One patient had no change in the nasolabial angle, and 3 patients had counterrotation of 1 degrees , 3 degrees , and 4 degrees . A postoperative physical examination revealed that no patient had developed bossae, tip asymmetries, or knuckling. In addition, the double break was maintained in all the study patients. CONCLUSIONS: Intermedial crural overlay is a reliable technique for achieving tip deprojection. Overall, the nasolabial angle is maintained (although in 3 patients, clinically insignificant counterrotation did occur). In addition, the length of the intermediate crura is reduced, but the double break is preserved. In the group of patients with thin skin and tip overprojection secondary to overdevelopment of the lower lateral cartilages, intermediate crural overlay achieves tip deprojection while controlling the nasolabial angle and preserving the natural curvature of the dome.

Reducing complications in rhinoplasty.

The dedicated rhinoplasty surgeon continues to acquire throughout his or her career an increasingly detailed understanding of the anatomy and the problems that occur related to rhinoplasty and a growing armamentarium of techniques to achieve improvement or correction. This article out-lines the authors' approach and discusses selected technical problems and approaches to reducing their occurrence. Focusing on the two essential goals-making the patient happy and making this the patient's only nasal surgery-primary rhinoplasty can be a uniquely rewarding experience for the patient and the surgeon.

Multimodality approach to sinus and nasal disorders: results of treatment as determined by a patient survey.

Patients with sinus and nasal disorders whose symptoms persist despite primary care may benefit from a referral to a dedicated nose and sinus center where all treatment modalities are available. The essential principle of a multimodality approach is that medical therapy, allergy treatment, and surgery are all important and useful tools. While various medical and surgical treatments of sinus and nasal disorders have been well described in the literature, overall assessments of comprehensive treatment are uncommon. For more than 7 years, the office practice of the senior author (D.G.B.) has been dedicated to the treatment of sinus and nasal disorders. In an effort to assess the results of the multimodality approach to therapy delivered there, we mailed questionnaires to 1,800 patients who had been treated at this practice over a 3-year period. Responses from 222 of these patients revealed that patients required less medication following treatment with a multimodality approach and that they expressed a high degree of satisfaction with the comprehensive care they received. In addition, most patients with asthma experienced relief of their asthma symptoms following treatment for sinonasal disease. We conclude that a stepwise, multimodality, specialty-center approach to treatment is beneficial for patients with persistent sinonasal disorders.

Postnasal drip and postnasal drip-related cough.

PURPOSE OF REVIEW: This article describes the pathophysiology and management of postnasal drip (PND) with and without cough. RECENT FINDINGS: PND is a common complaint in primary care and ear-nose-throat offices, and is often, but not always, associated with chronic cough. Because it lacks objective testing and its symptoms can be vague and variable, PND has become a catch-all diagnosis for a variety of nasal and throat-related symptoms. Studies have shown that the traditional pathophysiology of PND related to sinonasal disease does not clearly lead to chronic cough and that the cough from PND may be related to an airway sensory hypersensitivity rather than actual irritation from inflamed nasal secretions. SUMMARY: The article summarizes the current recommendations on evaluation and management of PND as well as brings to discussion new therapies and hypothesis regarding its pathophysiology.

A dedicated specialty center for nose and sinus care: an organized approach.

A specialty center focusing on a single, widespread medical problem and housing all treatment modalities is a revolutionary approach to medical treatment. Sinusitis, the most common chronic illness in the United States, is ideally suited to this approach. By housing the most advanced options for patients in a highly specialized treatment facility, attention is focused on the patient's problem, and treatment may be improved. In this article, an overview of the specialty center approach to sinus and nasal disorders is provided. State-of-the-art medical treatment, allergy evaluation and treatment, and surgical technology, including powered instrumentation and computerized image-guided surgery, are all employed in the treatment of functional nasal problems and cosmetic nasal requests. A subspecialty training program will allow for replication of this model for sinus and nasal care nationally. The Becker Nose and Sinus Center, LLC, is the first specialty center in New Jersey focused on diagnosing and treating patients who suffer from nasal and sinus disorders. The Nose and Sinus Center houses some of the most advanced options for patients in nose and sinus care in a highly specialized treatment facility and is a model for this organized approach to sinus and nasal care.

An algorithmic approach to the evaluation and treatment of olfactory disorders.

PURPOSE OF REVIEW: To review the current evidence in diagnosing olfactory disorders and suggest an algorithmic approach to patients with relevant complaints. RECENT FINDINGS: New literature suggests that the incidence of olfactory loss increases with age. Age-associated olfactory loss is often multifactorial and requires careful history and physical exam. Psychophysical tests have a role in screening patients at risk for Parkinson's and Alzheimer's disease, but there is lack of evidence regarding timing and patient selection. Prediction of olfactory improvement in patients with chronic rhinosinusitis (CRS) is difficult with variable results from different studies. Olfactory training is suggested to be an emerging modality in patients with postinfectious olfactory loss. SUMMARY: There is no standard treatment for olfactory loss. Each patient must be approached individually based on the suspected cause. Patients with CRS may require medical management and surgical treatment for alleviation of their olfactory dysfunction.

Nasal reconstruction: the state of the art.

PURPOSE OF REVIEW: Cutaneous malignancies of the nose are common problems and create the need for nasal reconstruction within many otolaryngology practices. In spite of the fact that such reconstruction is an ancient art, there continue to be innovations and advances that allow for more predictable and functional long-term results. RECENT FINDINGS: Analyzing the nasal defect through an organized algorithm can be useful in many circumstances, especially when one needs to consider vectors of tension, minimizing alar base asymmetry, resultant scars, and preservation of the intranasal airway. Application of the principle of aesthetic subunits has greatly improved the cosmetic results for many large nasal defects, and there have been some proposals to modify the original definitions and concept. Structural reconstruction is paramount with complex defects that involve the nasal framework or with those that are located in functionally critical areas. Autogenous cartilage grafting remains the gold standard, but the use of alloplastic and homograft materials for grafting continues to be reported as an alternative. Internal lining repair is essential with larger defects and the versatility of intranasal flaps is understood, but at times not available. Other flaps have been described and may be useful on such occasions. SUMMARY: There are many considerations during nasal reconstruction, and the surgeon must be facile with a variety of options within his/her armamentarium.

Cerebrospinal fluid leak after acoustic neuroma surgery: a comparison of the translabyrinthine, middle fossa, and retrosigmoid approaches.

OBJECTIVE: To determine whether the choice of surgical approach affects the rate of postoperative cerebrospinal fluid leakage in patients who have undergone surgical resection of acoustic neuroma. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary referral center. PATIENTS: Three hundred patients who underwent surgery for acoustic neuromas were selected by consecutive medical record number until 100 resections via each surgical approach (translabyrinthine, middle fossa, and retrosigmoid) had been gathered. MAIN OUTCOME MEASURES: Surgical approach used, cerebrospinal fluid leak incidence, tumor size, patient age. RESULTS: Postoperative cerebrospinal fluid leak of any severity was observed in 13% of translabyrinthine, 10% of middle fossa, and 10% of retrosigmoid patients. These difference in the rate of cerebrospinal fluid leakage were not statistically significant (p = 0.82). The majority of leaks were managed conservatively with fluid and activity restriction, often accompanied by a period of lumbar subarachnoid drainage. There was a need to return to the operating room for a definitive procedure in 4% of translabyrinthine, 2% of middle fossa, and 3% retrosigmoid patients; again not statistically different among the approaches (p = 0.43). Tumor size was not correlated with cerebrospinal fluid leak rate (p = 0.13). Patient age, for patients older than 50 years, was suggestive of increased odds of cerebrospinal fluid leak (p = 0.06). CONCLUSION: Neither surgical approach nor tumor size affects the rate of postoperative cerebrospinal fluid leakage or the necessity of managing a leak with a return to the operating room. Cerebrospinal fluid leakage rates have remained stable in recent decades despite numerous innovative attempts to improve dural closure, seal transected air cell tracts, and occlude anatomic pathways. The finding that leak rates were similar among three dissimilar surgical techniques suggests that factors other than techniques of wound closure, such as transient postoperative rises in cerebrospinal fluid pressure, may be responsible for these recalcitrant cases.

Treatment of nasal obstruction from nasal valve collapse with alar batten grafts.

Nasal obstruction may require treatment with rhinoplasty techniques. One cause of nasal obstruction is known as nasal valve collapse. This refers to narrowness and weakness at the nasal valve, the narrowest part of the nasal airway. There are a number of surgical approaches available to treat nasal valve collapse. Selection of the appropriate surgical intervention depends on proper identification of the anatomic cause of the collapse. Alar batten grafts are especially useful for addressing nasal valve collapse caused by a weak nasal sidewall. In this report, we review the senior author's experience with the use of alar batten grafts for nasal valve collapse. Twenty-one patients had septoplasty with placement of alar batten grafts; all patients noted improvement in their nasal breathing. Seven patients underwent ear cartilage harvest with alar batten grafts, and five of them noted improvement, one noted partial improvement, one noted no improvement. Six patients underwent revision septorhinoplasty with alar batten grafting, and ten patients underwent revision septorhinoplasty with ear cartilage harvest and alar batten grafting. These patients all reported improvement in their nasal breathing postoperatively. Six patients underwent revision rhinoplasty (no septoplasty) with ear cartilage and battens. These patients hold special interest because no other intranasal procedures were performed that affected nasal breathing. All six of these patients reported significant improvement of their nasal breathing and all patients were satisfied with their postsurgical cosmetic appearance. The nasal valve area is considered to be the location of the least cross-sectional area in the nose. When narrowing of the nasal valve is a result of collapse of the nasal sidewall, alar batten grafts are a useful technique to address the patient's nasal obstruction.

Pearls and pitfalls: medico-legal considerations for sinus surgery.

PURPOSE OF REVIEW: Patients being treated for chronic rhinosinusitis, whether via medical or surgical means, account for a significant percentage of all medical malpractice claims against otolaryngologists. In this study, we present suggestions to help otolaryngologists safeguard against unnecessary claims. RECENT FINDINGS: A significant proportion of malpractice claims associated with sinus surgery refer to failure of the physician to provide proper and complete informed consent. Poor physician communication and interpersonal skills, withholding information, and the impression that the physician is rushed and uninterested in patients' concerns appear to be associated with a higher risk of litigation. SUMMARY: For endoscopic sinus surgery, there are no set standards that delineate which complications are to be discussed; however, a frequently quoted suggestion has been to discuss complications specific to a procedure that occur in more than 1% of cases or are considered catastrophic in nature. Otolaryngologists should keep in mind that smell disturbances are common after endoscopic sinus surgery and consider discussing smell disorders as a potential risk during the informed consent process. If there will be a different physician performing the surgery, this should be discussed with the patient, and written in the consent. The surgeon should ensure that the patient understands the risks and the alternatives to surgery. Ideally, documentation is created that attests that the physician solicited and answered all of a patient's questions. When a complication occurs or if a patient is unhappy with the outcome of surgery, the physician should take extra care and time addressing the issue directly with the patient. Diligent documentation at every point is a crucial safeguarding step.

Evaluation of sinus computed tomography scans: a collaborative approach between radiology and otolaryngology.

PURPOSE OF REVIEW: Sinus computed tomography (CT) interpretation is subject to individual variation. We propose a template-driven approach as a method to ensure CT interpretation that is complete and efficient. RECENT FINDINGS: Recent years have seen the description of newly noted anatomic abnormalities in the paranasal sinuses that should be noted during sinus CT interpretation. SUMMARY: There exists significant variation in the methodology by which sinus CT scans are interpreted and the findings are reported. We believe that it will benefit radiologists and otolaryngologists alike to use a simple, template-driven approach to describe the findings encountered on a sinus CT. In this study, we present one such approach.

Middle ear effusion in adult ICU patients: a cohort study.

We conducted a prospective study of 74 adults-34 men and 40 women, aged 18 to 90 (mean: 60.2)-to determine the prevalence of middle ear effusion (MEE) among patients in the setting of an intensive care unit (ICU) and to compare the findings with those of a control group of non-ICU hospitalized patients. Other goals were to identify risk factors associated with MEE in ICU patients and to evaluate any association with fever. Both groups included 37 patients. MEE was present in 19 patients (51.4%) in the ICU group, compared with only 2 patients (5.4%) in the control group (p < 0.01; odds ratio: 18.5; 95% confidence interval: 3.9 to 88.3). In the ICU group, there were statistically significant associations between MEE and both the use of mechanical ventilation (p = 0.03) and the use of sedation (p = 0.02). No significant relationships were seen in terms of length of stay, body position, the use of an endotracheal tube, the length of ventilation, and the use of a feeding tube. Fever was present in 8 ICU patients (21.6%) and 3 controls (8.1%), but none of the fevers was associated with MEE. We conclude that adult ICU patients have a high prevalence of MEE (51.4% in our sample) that is perhaps unrecognized. We believe that MEE in these patients is most likely related to altered consciousness, sedation, and mechanical ventilation. MEE was an unlikely cause of fever.