Centripetal endoscopic sinus surgery in rhinogenic headache.

OBJECTIVES: The aim of this manuscript is to analyse a diagnostic protocol to select correctly patients with Rhinogenic Headache Contact Point (RH) and to investigate the effect of surgical treatment and medical therapy in pain relief. METHODS: A prospective no-randomized study selected adult patients with headache and nasal alteration at CT exam or endoscopic vision with positive response to test with nasal spray with corticosteroids and antihistamine or/and local anesthesia test to the contact points. MIDAS score, intensity score, daily duration of symptoms, frequency of headache in the last month were collected in patients who performed surgery and in patients who performed medical therapy. RESULTS: Following the inclusion, 415 patients were selected for this study. 302 patients performed nasal surgery (septoplasty, turbinoplasty and/or endoscopic surgery with centripetal technique), 113 performed medical therapy. There was a statistically significant improvement in MIDAS score, intensity score, daily duration of symptoms, frequency of headache in the last month in patients who performed surgery and in patients who performed medical therapy. Regarding the comparison between patients who performed surgery (Group A) and patients who performed only medical therapy for RH (Group B), better outcomes were obtained by Group A. Considering the daily life handicap index, the lowest handicap was obtained in Group A. CONCLUSION: This study demonstrates that surgery, using in some cases centripetal technique, gives an improvement statistically significant than medical therapy in RH. The use of nasal spray with corticosteroids and with anti-histamine is a good method in the diagnosis of RH, especially in patients with anatomical variants such as concha bullosa, agger nasi cells and Haller cells.

The centripetal endoscopic sinus surgery in patients with cystic fibrosis: A preliminary study.

OBJECTIVES: The main aim of this study is to analyze the possible differences between clinical, demographic or genetic characteristics, in Cystic Fibrosis (CF) patients with chronic rhinosinusitis (CRS) with different phenotype. The secondary objective is to describe the possible benefit of surgery with Centripetal Endoscopic Sinus Surgery (CESS). METHODS: The study includes 56 who performed CT scan of the paranasal sinuses. They were divided in 3 group according to phenotype: CRS without Nasal Polyps (NP); CRS with NP; CRS complicated with Mucocele. The clinical symptoms, age, gender, genotype, microbial colonization and pulmonary disease stage were collected and analyzed to assess possible statistically significant differences. Regarding the 7 patients who performed CESS surgery, the number of hospitalizations, intravenous (iv) antibiotic courses, respiratory exacerbations, the FEV1, the Lund-Mackay Score (LMS) and the SNOT 22 were evaluated before and 1 year after surgery. RESULTS: No statistically significant differences regarding clinical symptoms between the 3 groups were identified (p > 0.05). Furthermore, there were no differences in age, gender, genotype, microbial colonization and pulmonary disease stage (p > 0.05). Regarding the patients who performed CESS, no significative difference in FEV1 progression was found. A reduction in hospitalization, pulmonary exacerbation and in the number of iv antibiotic courses resulted statistically significant different (p = 0.004; <0.001 and <0.001 respectively). A significant improvement in SNOT-22 and LMS (p < 0.001) was obtained. CONCLUSION: Radiological monitoring of the rhinosinus disease is necessary regardless of the clinical expression of the disease. The presence of CRS with NP complicated by mucocele is frequent and independent of the patient's age and clinical manifestations. An extensive surgical approach could represent the gold standard for patients with CF in consideration of the potential important advantages to perform a total toilet of all the sinuses and nasal cavities and at the same time eliminating a potential microbiological reservoir.

Imaging features of perineural and perivascular spread in rapidly progressive rhino-orbital-cerebral mucormycosis: A case report and brief review of the literature.

BACKGROUND: Rhinocerebral mucormycosis (ROCM) is an opportunistic fungal infection originating from the paranasal sinuses with extension to the brain. A delayed diagnosis can rapidly result in a poor prognosis. ROCM commonly affects patients with diabetes or immunocompromised states with a variable progression. CASE DESCRIPTION: We report the case of a 59-year old patient with an untreated diabetes who developed a ROCM with rapidly progressive neurological symptoms. From the onset of sinus pain, nasal congestion, he rapidly developed facial swelling and masticatory dysfunction. The patient underwent sinus surgery which allowed Rhizopus oryzae to be isolated. Accordingly, a systemic therapy by intensive intravenous amphotericin B was started. Nevertheless, the infection rapidly resulted in bilateral cavernous sinuses thrombosis and occlusion of the left internal carotid artery providing the subsequent patient death. CONCLUSION: Mucormycosis is a life-threatening fungal infection in diabetic and/or immunosuppressed patients. Our case demonstrates the three main mechanisms for infection spreading that are direct, perineural, and perivascular diffusion. Clear identification of the main risk factors, proper assessment of clinical features, and radiological findings may improve the chance for an early diagnosis and patient survival.

Triplane augmentation mammaplasty.

BACKGROUND: Sub-muscular positioning of breast implants requires interrupting as well as disinserting both the abdominal and sterno-chondral fibers of the pectoral muscle; this can produce a muscular strength reduction which reveal bothering and is often detected in some daily motions, such as cutting bread into slices. MATERIAL AND METHODS: The revision of anatomy and literature induced the authors to search for a conservative approach for breast augmentation. They describe a new technique defined "Tri-plane" where the muscular fibers are not cut but simply split to create the pocket for breast implants. RESULTS: Our experience evidenced that this technique gave good aesthetic results together with a more significant projection of the NAC without any strength diminution either in adduction or abduction of the arms. CONCLUSIONS: This technique is a valid alternative to other techniques of breast augmentation as it conjugates the advantages of sub-glandular and sub-muscular implants without muscular deficit.