Long-term outcome analysis of functional endoscopic sinus surgery: correlation of symptoms with endoscopic examination findings and potential prognostic variables.

One hundred eighty-two patients were evaluated after functional endoscopic sinus surgery. The goal was to establish whether any anatomical finding correlated with symptoms and to find any historical predictors of symptomatic failure. Of all physical findings reviewed, only scarring of middle meatal antrostomy and scarring of the ethmoids approached significance in predicting poor outcome. Surprisingly, of the historical factors reviewed, only gastroesophageal reflux disease was statistically significant as a predictor of poor symptomatic outcome.

Suspended circummandibular wire fixation for mixed-dentition pediatric mandible fractures.

OBJECTIVE: To introduce and evaluate the technique of cirummandibular wires with piriform rim suspension (CMW-PRS) combined with arch bars and a fracture site bridle in the treatment of mixed-dentition pediatric mandible fractures. DESIGN: Five male patients (mean age, 8.2 years [age range, 7-10 years]) with an isolated mixed-dentition mandible fracture were treated with the CMW-PRS technique at the University of Texas Health Science Center, San Antonio, from 1985 to 1987 and at the University of Missouri, Columbia, from 1992 to 1995. Clinical and radiographic fracture healing, somatosensory status, and complications were evaluated. RESULTS: All patients demonstrated clinical union to their preinjury occlusion by 3 or 4 weeks. They remained without complications until they were no longer available for follow-up. Panoramic radiographs supported the findings of clinical examinations throughout the study, and no radiographic abnormalities were found. There were no somatosensory disturbances of the lingual or mental/inferior alveolar nerves. One patient required a tracheostomy unrelated to the procedure. CONCLUSION: The CMW-PRS technique combined with arch bars and a fracture site bridle wire achieved equivalent historical results when compared with the dental splint. The potential advantages and disadvantages of the CMW-PRS technique compared with those of monocortical bone plating, as well as the significant advantages of the CMW-PRS over the dental splint, are discussed in the text.

Transcalvarial suture fixation for endoscopic brow and forehead lifts.

OBJECTIVE: To evaluate the safety and effectiveness of transcalvarial suture fixation during endoscopic repair of brow ptosis. DESIGN: Case series. SETTINGS: A private ambulatory surgicenter and a Veterans Affairs Hospital. PARTICIPANTS: Fifty patients with brow ptosis with minimum follow-up of 12 months. RESULTS: Patients had improvement in brow position in all cases. There were no adverse effects of performing cortical tunnels and suture fixation. CONCLUSION: Transcalvarial suture fixation can be performed safely with good to excellent results and avoids the need for screw or plate fixation.

Comparison of mRAST and CAP with skin end point titration for Alternaria tenuis and dermatophagoides pteronyssinus.

There has been a recent explosion of new in vitro tests for the diagnosis of allergies. At present there is no general agreement on which type of in vitro test is best. Recently our hospital switched in vitro testing from the modified radioallergosorbent system (mRAST) to the Pharmacia CAP system (CAP). While changing in vitro testing techniques, 47 patients were tested with both the mRAST and CAP tests. Comparisons were made between the mRAST and CAP results of Alternaria tenuis and Dermatophagoides pteronyssinus allergens. These results were then compared with the results of patients who also underwent intradermal skin testing based on end point titration techniques.

Immunotherapy in patients undergoing functional endoscopic sinus surgery.

A total of 283 consecutive patients with chronic sinusitis underwent functional endoscopic sinus surgery. There were 72 allergic patients and 211 nonallergic patients. Data were collected on the effect of immunotherapy on middle meatotomy patency, synechiae formation, and recurrent polyps in allergic patients. Data supported the following conclusions: (1) Immunotherapy given either before or after surgery does not statistically influence middle meatotomy patency, synechiae formation, or recurrence of polyps after functional endoscopic sinus surgery. However, the data do suggest, for all three outcome parameters, that allergic patients who undergo immunotherapy do better than those who do not undergo immunotherapy and, with the exception of recurrent polyps, do as well as nonallergic patients. (2) The prevalence of preoperative polyps is the same for allergic and nonallergic patients in this study, but polyp recurrence is higher in allergic patients. (3) Approximately 40% of allergic patients who began preoperative immunotherapy stopped immunotherapy after surgery because their allergic symptoms resolved or were minimal. A comment regarding this observation is provided.

Functional endoscopic sinus surgery in patients with chronic sinusitis and asthma.

Twenty asthma patients who underwent functional endoscopic sinus surgery for chronic sinusitis were studied. Medical records and questionnaire data for these 20 patients were studied regarding the impact of sinus disease and functional endoscopic sinus surgery on their asthma. We found that 95% reported that their asthma was worsened by their sinus disease (95% confidence interval, 0.74 to 0.99+), and 85% reported that functional endoscopic sinus surgery improved their asthma (0.60 to 0.97). Of the 13 patients who used both inhalers and systemic medication, 53.8% were able to eliminate some of their medication (0.21 to 0.79). Furthermore, 61.5% of these patients had a concomitant reduction in their inhaler use (0.28 to 0.85). All patients (six) who used only inhalers experienced a reduction in their inhaler use (0.54 to 1.00), and two patients were able to eliminate their inhalers completely. One of two patients who were steroid dependent was able to discontinue steroids after surgery. Of patients who used steroids intermittently (13), 53.8% were able to eliminate the use of steroids after surgery (0.21 to 0.79). Patients who required preoperative hospital admissions (4) and emergency room or urgent physician office visits (18) had a 75.0% and 81.3% (p < 0.001) reduction in visits, respectively, after surgery. Because 43% of the cost of asthma is the result of hospitalizations and emergency department/urgent physician office visits, a significant impact on health care costs can be realized with functional endoscopic sinus surgery in this patient population.

Functional endoscopic sinus surgery in patients with normal computed tomography scans.

Eighteen patients were operated on by functional endoscopic sinus surgery who had no ostiomeatal unit obstruction on computed tomography scan and had unremarkable paranasal sinuses. These patients also had no apparent ostiomeatal unit obstruction on diagnostic nasal endoscopy. Data were collected on these patients regarding the impact of very limited functional endoscopic sinus surgery on their principal complaint of recurrent sinusitis with facial pain/headache thought to be of sinogenic origin. Sixteen patients (88.9%) had a reduction in the number of sinus infections requiring antibiotic therapy. This reduction was significant at p < 0.0001. Twelve of 14 patients whose facial pain/headache was believed to be of sinogenic origin had a significant reduction in severity (95% confidence interval, 49.2% to 95.3%). We discuss the role of reversible nasal mucosal disease in the pathophysiology of recurrent rhinosinusitis in this patient population. This was a very small, select group of patients who had specific complaints and had had medical treatment failures. This therapy is not recommended for every patient, but only a select few with classic complaints of sinus headaches or recurrent sinusitis and negative computed tomography scans.

Paranasal sinus computed tomography scan findings in patients with cystic fibrosis.

Seventy paranasal sinus computed tomography scans of patients with cystic fibrosis were compared with those of age-matched control groups of randomly selected chronic sinusitis patients without cystic fibrosis to determine whether differences in disease patterns existed. In patients older than 10 years, frontal sinus agenesis and maxilloethmoid sinus opacification were significantly more prevalent in patients with cystic fibrosis than in chronic sinusitis patients without cystic fibrosis. Medial bulging of the lateral nasal wall was significantly greater in patients with cystic fibrosis than in chronic sinusitis patients without cystic fibrosis in patients older than 5 years. On the basis of these findings, a diagnostic triad of radiologic findings for cystic fibrosis detection is presented, as well as its clinical implications.

Symptom outcome after functional endoscopic sinus surgery in patients with cystic fibrosis: a prospective study.

Twenty-nine consecutive patients with cystic fibrosis were offered functional endoscopic sinus surgery. Twenty-six of these patients underwent surgery. A symptom questionnaire was obtained from the patient or parent before surgery. At the end of the study this symptom questionnaire was again administered to the same individual, and 21 completed it. There were 14 male and 7 female patients, with a mean age of 12.3 years and a median age of 8.7 years. Mean follow-up was 34.3 months. Results for the following symptoms were significant: nasal airway obstruction was improved (p < 0.0002), olfactory function was improved (p < 0.0037), purulent nasal discharge was decreased (p < 0.001), and activity level was increased (p < 0.001). Other parameters are also reported in the text. In summary, this study prospectively studies the effects of functional endoscopic sinus surgery on symptoms in patients with cystic fibrosis. The study points out several significant areas of symptom improvement and supports the selective use of functional endoscopic sinus surgery in patients with cystic fibrosis. Indications for surgery are provided.

Modified approach to the subperiosteal rhytidectomy.

Our technique modifications include a systematic preauricular approach to the zygomatic arch and preservation of the temporal fat pad, which is left undisturbed. The preauricular extension permits greater access along the zygomatic arch, which may additionally reduce the risk of injury to the frontal branch of the facial nerve. Leaving the temporal fat pad undisturbed may help prevent a recently described late complication of temporal region depression that may be due to temporal fat atrophy from surgical trauma. By following the aforementioned steps, this technique can be performed efficiently and safely even if it is used infrequently.

Allergic rhinosinusitis in the pediatric population.

Allergic disease is very common in the U.S. population and even more common in children seen by otolaryngologists. Allergy causes or contributes to virtually all of the diseases in the respiratory tract that otolaryngologists, particularly otolaryngic allergists, evaluate and treat. The signs and symptoms of allergic disease in the pediatric patient are reviewed to improve the appreciation of the role of allergy in pediatric otolaryngology. Recent research developments, which are reviewed in detail in this article, underscore the importance of allergic, inflammatory response in rhinosinusitis. The key to long-term therapeutic success, particularly in pediatric rhinosinusitis, is management of the underlying allergic diathesis.

Paranasal sinus disease in patients with cystic fibrosis.

The enhanced understanding of the pathophysiology of cystic fibrosis (CF) has advanced significantly the management of this disorder, resulting in both an increased longevity and an improved quality of life. Sinonasal disease is an important aspect of CF. The goal of this article is to provide a current synopsis of CF sinonasal disease with an emphasis on disease symptomatology, physical signs, characteristic radiographic features, and outcome-based management options. When indicated, functional endoscopic sinus surgery has been shown to be a safe and effective treatment option for children with CF.

Masticatory muscle hyperactivity in temporomandibular disorders: is it an extrapyramidally expressed disorder?

Masticatory muscle hyperactivity appears to have an important role in temporomandibular disorders. A pathophysiological model for masticatory muscle hyperactivity is proposed that is centrally mediated, yet maintains support for present peripheral causes and therapies. In this hypothesis, masticatory muscle hyperactivity represents a mild extrapyramidal disorder distantly related to orofacial dyskinesias. Experimental evidence suggests a neurotransmitter imbalance in the basal ganglia, involving dopaminergic preponderance, or cholinergic and GABA-nergic hypofunction as the underlying cause.

Endoscopic partial inferior turbinectomy using a power microcutting instrument.

A technique for removing part of the inferior turbinate with a powered instrument is presented. This new technique is safe, quick, easy to teach, predictable and enables removal of the same amount of tissue and bone as is removed with other techniques of partial inferior turbinectomy.

Fracture of the anterior maxillary alveolar ridge with laryngoscopy.

The following case report describes a patient who suffered an anterior maxillary alveolar ridge fracture resulting from difficult laryngoscopy and intubation. An unfortunate sequelae of this injury was the loss of two maxillary central incisors due to persistent mobility despite long term dental stabilization. To the authors' knowledge, fractures involving the premaxilla have not been reported as a complication of laryngoscopy and intubation.

Unsuspected failure of nasotracheal intubation.

This report describes a patient with a clinically normal airway who could not, even with the aid of a fiberoptic bronchoscope, be intubated nasotracheally. Failure was due to a large bony prominence projecting anteriorly into the nasopharynx from the body of the first cervical vertebrae. This bony prominence deflected both the endotracheal tube and fiberoptic tube anterolaterally such that they could not be aligned with the glottic opening for passage into the trachea. To our knowledge, this is the first reported case of "failure" of nasotracheal intubation associated with this anatomic abnormality.

Modified sagittal split technique for patients with a high lingula.

Unfavorable fractures of the proximal fragment during the sagittal ramus split procedure, although uncommon, occur with an incidence ranging between 3% and 6.6%. One anatomic feature that may predispose to an unfavorable fracture is a thin mandibular ramus in the region of the medial osteotomy. One particular situation that can increase the risk of an unfavorable fracture is a lingula that is situated very high on the mandibular ramus. Even in a normal-sized mandibular ramus, a high lingula places the medial cut in a thin region where there is little or no cancellous bone. The technique presented is a modification of the sagittal split osteotomy which can assist the surgeon in preventing an unfavorable fracture should an unusually high lingula or a thin ramus be encountered.