Acute sinusitis.

Sinusitis is a common patient complaint that carries with it a large economic burden. It is one of the most common reasons patients visit their primary care physician. Acute bacterial rhinosinusitis (ABRS) can be distinguished from other forms of rhinosinusitis based on symptom duration of <4 weeks in a patient with purulent rhinorrhea associated with facial pain or pressure. Native upper aerodigestive tract bacteria are the most common etiologic agents. Treatment of ABRS is targeted primarily at symptom improvement. Amoxicillin can be used based on the clinical scenario and patient comorbidities. Computed tomographic scans are reserved for complicated presentations or when there is concern for intracranial extension or other complications. A systematic approach to ABRS will allow for improved patient quality of life and a decreased overall economic burden of this common entity.

Aural Blast Injury/Acoustic Trauma and Hearing Loss.

Hearing is a critical sense to military performance. The ability to detect, identify, and localize sounds, the ability to maintain spatial awareness on the battlefield and the awareness to control one's own noise production can be vital to troop's stealth, survivability, and lethality. Hazardous noise is an environmental public health threat encountered in training at war, and in many off-duty activities. The risk to hearing and the resultant damage from any of these hazardous exposures is generally invisible, insidious and cumulative. Regardless of the source of injury, hearing loss degrades the sensor that integrates Service Members with their environment, provides for unity of effort, and ensures command and control.Acoustic trauma-induced hear loss and tinnitus are the two most prevalent disabilities in veterans, with over 765,000 cases in the Gulf War era alone. To counter this threat, it is necessary to push for early identification and early intervention through a trusted surveillance system. Success will require advocacy, education, and encouragement of self-reporting for evaluation following symptomatic noise exposures. This Clinical Practice Guideline (CPG) is a step to ensure the hearing health, readiness, protection, and care of Service Members. This will in turn optimize troop performance and minimize injury risk and mishap.

The joint facial and invasive neck trauma (J-FAINT) project, Iraq and Afghanistan 2003-2011.

OBJECTIVE: Define the number and type of facial and penetrating neck trauma injuries sustained in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). STUDY DESIGN: Retrospective database study. SETTING: Tertiary care level I trauma center. SUBJECTS AND METHODS: The Joint Theater Trauma Registry (JTTR) was queried for data from OIF and OEF from January 2003 to May 2011. Information on demographics; type and severity of facial, neck, and associated trauma injures; and impact on overall mortality was recorded. RESULTS: There were 37,523 discrete facial and penetrating neck injuries that occurred in 7177 service members. There were 25,834 soft tissue injuries and 11,689 facial fractures. The most common soft injury sites were the face/cheek (48%), neck/larynx/trachea (17%), and mouth/lip (12%). The maxilla (25%), mandible (21%), and orbit (19%) were the most common facial fracture sites. The most common mechanism of injury was penetrating (49.1%), followed by blunt (25.7%), blast (24.2%), and other/unknown/burn (1%). Injuries were associated with an overall mortality rate of 3.5%. The highest risks for mortality were treatment at a level IIa facility, female sex, prehospital intubation, and blast injury. Most injuries were mild to moderate. CONCLUSION: Facial and penetrating neck trauma are common in modern warfare. Most injuries are minor to moderate and survivable. Training and potential body armor updates can be made. Medical personnel deploying to support OIF and OEF could benefit from specific training in the management of facial and penetrating neck injuries. A surgeon skilled in managing these injuries would likely be beneficial in a deployed setting.

Cadaveric comparison of canine fossa vs transnasal maxillary sinus access.

OBJECTIVE: Anatomic limitations complicate complete eradication of debris from the maxillary sinus using an exclusively transnasal (TN) endoscopic technique. Creation of a canine fossa trephination (CFT) permits a more direct approach than removal via the maxillary ostium. METHODS: Microdebrider eradication of debris completely filling the maxillary sinus was performed on 5 thawed fresh-frozen cadaver heads (10 sides) using a TN or CFT approach. Postdebridement computed tomography (CT) scanning assessed remaining debris. Additional outcome measures included time of debris removal, number of different angled blades utilized, and clogging. RESULTS: A significantly greater amount of debris was left after the TN approach compared with CFT (3.88 cm(3) vs 2.88 cm(3), p = 0.015). Median blade utilization was significantly higher with the TN approach vs CFT (4 vs 1, p < 0.002). Time for debris eradication with CFT was similar regardless of expertise (323.4 vs 272.4 seconds, p = 0.21), but the TN approach showed a statistical difference in time-to-completion (698.8 vs 438.51 seconds, p = 1.7 × 10(-5)). CONCLUSION: Controversy surrounds the appropriate application of CFT due to disease process and approach-related morbidity. Rhinologists should have numerous well-studied options at their disposal. This model suggests that maxillary debris removal is accomplished more thoroughly with fewer microdebrider blades when a CFT approach is employed.

Improved function of prototype 4.3-mm Medtronic Quadcut microdebrider blade over standard 4.0-mm Medtronic Tricut microdebrider blade.

OBJECTIVE: Test performance of a new prototype microdebrider blade. The commercially-available, standard 4.0-mm Medtronic straight Tricut blade was tested against the new, prototype 4.3-mm Medtronic straight Quadcut blade in experimental surgical conditions utilizing both a nasal polyp (NP) analog (raw oysters) and an allergic fungal sinusitis (AFS) analog (minced beef cat food). METHODS: Both sides of 5 thawed, fresh-frozen cadaver heads were utilized for NP analog removal. AFS analog was removed out of specimen containers. A total of 10 paired data points were collected for time of surgical removal and number of clogs comparing the 2 blades. RESULTS: For simulated AFS debris, the prototype clogged less than the standard blade (0 vs 4.5, p < 0.0001). There were no clogs noted for either blade with the NP analog. Time for debris eradication was significantly improved for both AFS analog (147.4 vs 262.0 seconds, p < 0.0001) and NP analog (43.7 vs 112.1 seconds, p < 0.0001). CONCLUSION: The prototype blade offers faster debris and polyp removal and clogs less in the setting of allergic fungal debris. As the new blade is faster and more aggressive, introduction into a surgical setting should be guarded with an appropriate degree of caution.

Effect of head position and surgical dissection on sinus irrigant penetration in cadavers.

BACKGROUND: Effective treatment for recalcitrant rhinosinusitis requires unobstructed surgical marsupialization of sinus cavities and use of delivery systems that will topically penetrate the sinuses. AIMS: To determine the extent of sinus penetration achieved with nasal irrigation by varying the ostial size and head position. METHODS: Ten thawed fresh-frozen cadaver heads were dissected in a staged manner. After each stage of dissection, sinus squeeze-bottle irrigations were performed in three head positions, and endoscopes placed via external ports into the sinus cavities viewed the sinus ostia. An ordinal scale was developed to grade ostial penetration of irrigations. Three reviewers independently graded the outcomes. RESULTS: Irrigant entry into sinuses increased with ostial size (P < .001) and the greatest differential of improvement in sinus penetration is obtained at an ostial size of 4.7 mm. Stages 2 and 3 (larger sinus ostia) of maxillary and sphenoid dissections have statistically greater irrigant penetration relative to earlier stages. Frontal sinus irrigation is worse in vertex to ceiling head position. There does not appear to be any significant advantage to head position with maxillary and sphenoid sinuses. CONCLUSIONS: This study shows that the larger the sinus ostium, the better the penetration of irrigant into the sinus, with an ostium of at least 4.7 mm allowing maximal penetration in the maxillary and sphenoid sinuses. The same benefit was not noted in the frontal sinus. Head position was only relevant to the frontal sinus where less penetration was seen with the head neutral (vertex to ceiling) position when compared to forward angled positions.