The fate of the bone graft in cerebrospinal fluid rhinorrhea endoscopic repair for idiopathic intracranial hypertension: a retrospective case series analysis.

INTRODUCTION: Idiopathic intracranial hypertension (IIH) is a common cause of spontaneous cerebrospinal fluid (CSF) leaks necessitating surgical intervention, and grafting of septal, mastoid, or turbinate bone over the defect is increasingly performed to strengthen the repair of the primary defect. However, the postoperative fate of these grafted bone fragments is largely unknown. METHODOLOGY: We performed a retrospective study of patients at the University of Pennsylvania undergoing repair of spontaneous CSF leaks secondary to IIH. Preoperative and postoperative CTs were analyzed to determine the integration status of the transplanted bone. RESULTS: Fourteen patients with IIH and spontaneous CSF leak were analyzed, with a mean postoperative imaging follow-up period of four years. Thirteen patients (93%) had bone present on CT imaging, with 11 of these patients displaying evidence of bone integration. Two patients (14%) had a recurrent CSF leak in the same area, including the patient with absence of bone on imaging follow-up. CONCLUSIONS: Bone grafts frequently incorporate when used for repair of spontaneous CSF leaks associated with IIH. The rate of incorporation is comparable to bone grafts used for other etiologies of CSF leak, despite the increased pressure on the repair site. Any rigid repair of the leak site should likely be accompanied by treatment of the underlying intracranial hypertension to avoid leak recurrence.

Geochemical and Microbial Community Attributes in Relation to Hyporheic Zone Geological Facies.

The hyporheic zone (HZ) is the active ecotone between the surface stream and groundwater, where exchanges of nutrients and organic carbon have been shown to stimulate microbial activity and transformations of carbon and nitrogen. To examine the relationship between sediment texture, biogeochemistry, and biological activity in the Columbia River HZ, the grain size distributions for sediment samples were characterized to define geological facies, and the relationships among physical properties of the facies, physicochemical attributes of the local environment, and the structure and activity of associated microbial communities were examined. Mud and sand content and the presence of microbial heterotrophic and nitrifying communities partially explained the variability in many biogeochemical attributes such as C:N ratio and %TOC. Microbial community analysis revealed a high relative abundance of putative ammonia-oxidizing Thaumarchaeota and nitrite-oxidizing Nitrospirae. Network analysis showed negative relationships between sets of co-varying organisms and sand and mud contents, and positive relationships with total organic carbon. Our results indicate grain size distribution is a good predictor of biogeochemical properties, and that subsets of the overall microbial community respond to different sediment texture. Relationships between facies and hydrobiogeochemical properties enable facies-based conditional simulation/mapping of these properties to inform multiscale modeling of hyporheic exchange and biogeochemical processes.

Giant cell arteritis--an incidental finding.

Giant cell arteritis is a systemic, inflammatory, and vascular syndrome that requires early diagnosis and immediate management because of the risk of loss of vision. Local symptoms include headache, scalp tenderness, jaw claudication, visual disturbances, and scalp necrosis. Systemic symptoms include weight loss, fever, malaise, fatigue, and polymyalgia rheumatica. We describe a case that was identified histologically as an incidental finding after excision of a basal cell carcinoma from the parietal area of the scalp. A search of PubMed and Medline using the keywords "giant cell arteritis", and "incidental histopathological diagnosis" returned no similar previously published cases in the head and neck. We present this as an unusual and interesting case.

Role of outer-membrane cytochromes MtrC and OmcA in the biomineralization of ferrihydrite by Shewanella oneidensis MR-1.

In an effort to improve the understanding of electron transfer mechanisms at the microbe-mineral interface, Shewanella oneidensis MR-1 mutants with in-frame deletions of outer-membrane cytochromes (OMCs), MtrC and OmcA, were characterized for the ability to reduce ferrihydrite (FH) using a suite of microscopic, spectroscopic, and biochemical techniques. Analysis of purified recombinant proteins demonstrated that both cytochromes undergo rapid electron exchange with FH in vitro with MtrC displaying faster transfer rates than OmcA. Immunomicroscopy with cytochrome-specific antibodies revealed that MtrC co-localizes with iron solids on the cell surface while OmcA exhibits a more diffuse distribution over the cell surface. After 3-day incubation of MR-1 with FH, pronounced reductive transformation mineral products were visible by electron microscopy. Upon further incubation, the predominant phases identified were ferrous phosphates including vivianite [Fe(3)(PO(4))(2)x8H(2)O] and a switzerite-like phase [Mn(3),Fe(3)(PO(4))(2)x7H(2)O] that were heavily colonized by MR-1 cells with surface-exposed outer-membrane cytochromes. In the absence of both MtrC and OmcA, the cells ability to reduce FH was significantly hindered and no mineral transformation products were detected. Collectively, these results highlight the importance of the outer-membrane cytochromes in the reductive transformation of FH and support a role for direct electron transfer from the OMCs at the cell surface to the mineral.

Endoscopic sinus surgery: evolution and technical innovations.

Prior to the introduction of functional endoscopic sinus surgery, several surgeons had begun to use telescopes to perform surgical procedures in the nose and sinuses. However, the central concepts of functional endoscopic sinus surgery evolved primarily from Messerklinger's endoscopic study of mucociliary clearance and endoscopic detailing of intranasal pathology. The popularity of a combination of endoscopic ethmoidectomy plus opening of secondarily involved sinuses grew rapidly during the latter part of the twentieth century, and endoscopic intranasal techniques began to expand to deal with pathology other than inflammation. We present a review of the evolution of knowledge regarding the pathogenesis of inflammatory sinus disease since that point in time, and of the impact that this has had on the management of inflammatory sinus disease. We also detail the technological advances that have allowed endoscopic intranasal techniques to expand and successfully treat other pathology, including skull base and orbital disease. In addition, we describe evolving technologies which may further influence development within this field.

Real-time computed tomography image update for endoscopic skull base surgery.

INTRODUCTION: The development of computer-aided systems for endoscopic sinus surgery has enabled surgical navigation through diseased or surgically altered sinus anatomy with increased confidence. However, conventional computer-aided systems do not provide intra-operative updated computed tomography imaging. We describe the technical aspects of the xCAT, a new intra-operative mobile volume computed tomography scanner. TECHNICAL REPORT: A patient with a malignant melanoma unwittingly removed at another hospital underwent surgery for removal of the lateral nasal wall and directed biopsies, in an attempt to identify the site of tumour origin. The procedure was performed with the GE InstaTrak 3500 Plus computer-aided system, updated with intra-operative computed tomography images. Intra-operative, updated images were integrated successfully into the InstaTrak system, and these images were consistent with the observed endoscopic anatomy. CONCLUSION: The xCAT intra-operative mobile volume computed tomography scanner is a technological advancement that can assist the endoscopic sinus surgeon when performing complex rhinological and skull base procedures.

Treatment of chronic rhinosinusitis with high-dose oral terbinafine: a double blind, placebo-controlled study.

OBJECTIVES: To evaluate antifungal terbinafine in patients with chronic rhinosinusitis. STUDY DESIGN: Randomized, double-blind, placebo-controlled multicenter pilot study. METHODS: Fifty-three adults with chronic rhinosinusitis received terbinafine 625 mg/day (n = 25) or placebo (n = 28) once daily for 6 weeks. Sinus secretions were collected at screening for mycology. Computed tomography was graded for extent of opacification at baseline and at week 6 using a modification of the Lund-Mackay scoring system. Patients recorded rhinosinusitis symptoms on a visual analogue scale and completed the Rhinosinusitis Disability Index. RESULTS: Positive fungal cultures were found in 41 of 53 patients (17 terbinafine, 24 placebo). (Two subjects from the Terbinafine group and one subject from the control group had no week 6 data). The mean opacification scores pre- and posttreatment for the entire study group improved from 24.2 to 22.5 in placebo (n = 26) and from 26.3 to 24.2 in terbinafine group (n = 23). The least squares means for percent change from baseline (SE) were -6.0 (8.7) for placebo compared with -7.2 (8.1) for terbinafine; 95% confidence interval for treatment difference (-18.9, 21.1); P = .91. Results were similar when only patients with positive fungal cultures were evaluated in the efficacy analysis. Investigator therapeutic evaluations and sinus symptom scores were not significantly different between the two groups at baseline or at treatment completion. CONCLUSION: Treatment with terbinafine failed to improve the symptoms or radiographic appearance of chronic rhinosinusitis even when nasal irrigation samples were positive for fungus on culture. One consideration is that the fungi isolated were not a major pathologic factor in this cohort. It is also possible that, even at high dose, terbinafine may not have maintained therapeutic levels in the nasal secretions.

Topical adrenaline and cocaine gel for anaesthetising children's lacerations. An audit of acceptability and safety.

OBJECTIVES: (1) To assess the acceptability of a gel solution of adrenaline (epinephrine) (1 in 2000) and cocaine (5%) for anaesthetising children's facial lacerations to the child, parent, and operator. (2) To assess the safety of the current protocol. SETTING: The emergency unit of a large university hospital. METHODS: All patients who were treated with topical adrenaline and cocaine (topAC) gel over a six month period were entered into a prospective audit (n = 75). Patient details, the nature and cause of the injury, and any treatment carried out were all recorded. The acceptability to children over 3 years of age, was assessed by the use of the Wong Baker face scale, in which 0 represents "no hurt" and 5 represents "hurts worst". The acceptability to both the parent and the operator was assessed by the use of a 0 to 9 Likert scale, where 0 represented "very acceptable" and 9 represented "not at all" acceptable. RESULTS: (1) Children aged 3 years or older graded their pain during the procedure as having a mean value of 1.17 on the Wong Baker (0 to 5) scale. Parents graded acceptability on the Likert scale (0 to 9) with a mean score of 1.13. Operators using the same grading system, recorded a mean score of 1.75. (2) No toxic side effects were seen but the protocol was updated in line with evidence. CONCLUSIONS: Topical adrenaline and cocaine is an effective anaesthetic for suturing children's facial lacerations and is acceptable to child, parent, and operator alike.

Complications with intermaxillary fixation screws in the management of fractured mandibles.

A dedicated bicortical bone screw for temporary intraoperative intermaxillary fixation (IMF) during open reduction and fixation of mandibular fractures offers many benefits to surgeons and patients. We have used this system for 2 years and confirm the benefits over traditional methods of intermaxillary fixation. However, complications can arise. One hundred and twenty-two patients with mandibular fractures had IMF screws of which five (4%) developed complications intraoperatively and postoperatively. Complications included fracture of the screws on insertion, iatrogenic damage to teeth causing loss and bony sequestra around the area of screw placement.

Medical applications of electronic nose technology: review of current status.

Electronic noses, or artificial sensors of odorants. have been developed over the last ten years to perform a variety of identification tasks in various industries. This powerful technology is only beginning to be introduced in the field of medicine, but is promising in its potential to assist in diagnosis. This article reviews electronic nose technology and some initial investigations of potential applicability of the technology in the field of medicine.

Rigid nasal endoscopy versus sinus puncture and aspiration for microbiologic documentation of acute bacterial maxillary sinusitis.

Sinus puncture and aspiration is an invasive procedure that hinders patient enrollment in studies of acute bacterial maxillary sinusitis (ABMS). Pain and minor bleeding also limit its potential diagnostic utility in clinical practice. Cultures obtained by rigid nasal endoscopy were compared with those from sinus puncture and aspiration in 53 patients with ABMS; 46 patients were assessable. Considering recovery of Haemophilus influenzae, Moraxella catarrhalis, or Streptococcus pneumoniae from puncture and aspiration as the gold standard, endoscopy cultures demonstrated a sensitivity of 85.7% (95% confidence interval, 56.2-97.5), specificity of 90.6% (73.8-97.5), positive predictive value of 80% (51.4-94.7), negative predictive value of 93.5% (77.2-98.9), and accuracy of 89.1% (75.6-95.9). Ten adverse events related to puncture and aspiration occurred in 5 (9.6%) of 52 patients; there were no endoscopy-related adverse events. In our study, the largest to date, endoscopic sampling compared favorably with puncture and aspiration for identifying H. influenzae, M. catarrhalis, and S. pneumoniae in ABMS and produced less morbidity.

Revision endoscopic frontal sinus surgery.

Frontal sinusitis following functional endoscopic sinus surgery may represent persistent, recurrent, or iatrogenic disease. The narrow frontal recess is unforgiving of technical errors, and surgery within its confines requires ample training, skill, and patience. Revision surgery in this area, compromised by scarring and long-standing mucosal disease, demands even more of the endoscopic sinus surgeon. While successful treatment of this condition is a formidable task, strict attention to principles of proper medical and surgical therapy can increase the chances of a favorable outcome.

The ATLS course, a survey of 228 ATLS providers.

Advanced Trauma Life Support (ATLS) courses teach a system for the initial assessment and management of trauma patients that aims to optimise initial care and reduce mortality and morbidity, and have been adopted worldwide. This questionnaire survey characterised those who took up this particular educational resource in Scotland during a four year period after its introduction, and analysed how they felt it had affected their clinical competence. Irrespective of their previous level of training and experience, nearly all surgeons and anaesthetists who took this course felt that it had improved their clinical skills and other professional attributes. The significance of these results is discussed in the context of postgraduate surgical and anaesthetic training in Scotland.

Effects of long-term induced ostial obstruction in the rabbit maxillary sinus.

One of the widely proposed theories for mucocele formation is sinus ostial obstruction. Accordingly, this study was undertaken to investigate the long-term effects of ostial obstruction in the rabbit maxillary sinus and its potential role in the pathogenesis of mucoceles. Maxillary sinus ostial obstruction was induced on one side in eight Pasteurella-free White New Zealand rabbits using Histoacryl. The rabbits were housed in a Pasteurella-free zone for 24 weeks. At re-exploration, only three of the eight maxillary sinuses where ostial obstruction was induced showed pressure recording consistent with ostial obstruction. Mucociliary clearance activity was assessed using India ink. Swabs for culture were taken from the infected maxillary sinuses. Mucosal specimens for histopathological examination were harvested from one of the maxillary sinuses with obstructed ostium as well as from another sinus with nonobstructed ostium. The three maxillary sinuses with obstructed ostia showed gross evidence of infection and deranged mucociliary clearance, but no mucocele formation. Based on the findings of this study it is concluded that long-term ostial obstruction indeed plays a role in the pathogenesis of chronic sinusitis, but it did not induce mucocele formation in the rabbit maxillary sinus.

Surgical intervention for sinusitis in adults.

This article briefly reviews the latest developments in the indications for and performance of paranasal sinus surgery. Although the central role of medical therapy in the treatment of inflammatory chronic rhinosinusitis remains essentially unchanged, the past few years have seen a gradual evolution in the indications for, and the expectations of, sinus surgery. Although many controversies still exist in the optimal management of rhinosinusitis, especially regarding the treatment of chronic frontal rhinosinusitis, the long-term beneficial role of functional endoscopic sinus techniques in combination with medical therapy has become firmly established for patients who do not respond well to medical treatment alone.

Bone involvement in sinusitis: an apparent pathway for the spread of disease.

OBJECTIVES/HYPOTHESIS: To study the effects of bone involvement in experimentally induced sinusitis and the effect of involved bone on the overlying mucosa. STUDY DESIGN: Animal study. METHODS: Sinusitis was induced unilaterally with Pseudomonas aeruginosa in the maxillary sinus of 19 New Zealand white rabbits. At 6 weeks, the pathogenic organism was confirmed by culture, and a segment of the bone from the medial wall of the sinus implanted in a submucosal pocket in the opposite sinus. The rabbits were killed at predetermined time intervals up to 13 weeks from sinusitis induction, and en bloc sinus sections were decalcified and stained. RESULTS: The implanted bone reabsorbed partially or totally in all specimens. However, the study revealed clear histological evidence of bone involvement adjacent to the infected sinuses and the bony changes extended to the noninfected side in all specimens. The histological findings were identical to those seen in chronic osteomyelitis. CONCLUSIONS: This study demonstrates the ability for pseudomonal sinusitis, at least in the presence of surgical intervention, to involve bone at a distance from the site of primary infection in the absence of intervening mucosal disease. If confirmed with additional organisms and models, these findings have significant implications for the therapeutic management of chronic sinus disease.

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.