History of Dorsal Preservation Surgery: Seeking Our Historical Godfather(s) for the "Push Down" and "Let Down" Operations.

There are 2 approaches for lowering the osseocartilaginous nasal dorsum. The most frequently used method includes resection of the osseocartilaginous nasal dorsum. The second method is based on preservation of the osseocartilaginous nasal dorsum. The concept of dorsal preservation surgery is to preserve, not resect, the nasal bones and upper lateral cartilage. Reduction rhinoplasty with preservation of the nasal dorsum is not only possible, but results in a natural appearing postoperative dorsal esthetic line. Thus, the rhetorical question: Why reconstruct the nasal dorsum when you can simply preserve it?

Preservation Rhinoplasty: The Endonasal Cottle Push-Down/Let-Down Approach.

Preservation rhinoplasty is a new term for an old technique. The authors have used the endonasal push-down and let-down techniques that are attributed to Dr Maurice Cottle throughout their careers on select patients with excellent success. The endonasal Cottle technique allows the authors to manage the nasal dorsum in a conservative fashion, reducing the need for routine restructuring of the middle third and nasal dorsum. The details of their approach are presented in this publication.

An immunologic test for chronic rhinosinusitis based on free intranasal eosinophilic major basic protein.

BACKGROUND: A histologic hallmark of chronic rhinosinusitis (CRS) is an eosinophilic inflammation, present with and without nasal polyposis and independent of atopy. Eosinophils migrate through nasal tissue including the epithelium into the nasal airway mucus, where they form clusters and degranulate, releasing granule proteins including the toxic major basic protein (MBP). Specific biomarkers for CRS, which could be used as a diagnostic test for CRS with a high sensitivity and specificity, are presently lacking. Recently, an enzyme-linked immunosorbent assay (ELISA)-based test for MBP in nasal airway mucus received regulatory approval. METHODS: A new assay was specifically developed to detect released MBP in airway mucus. MBP levels in nasal mucus of 85 randomly selected CRS patients diagnosed by endoscopy, computed tomography (CT) scans and symptoms were compared to 13 healthy controls and 5 disease controls (allergic rhinitis). RESULTS: Overall, 92% (78/85) of CRS patients' mucus were positive for MBP (mean 7722 ng/mL) vs none of 13 healthy controls and none of 5 allergic rhinitis patients (<7.8 ng/mL; p < 0.000000000002). In this study, the MBP ELISA had a 92% sensitivity and 100% specificity for CRS. CONCLUSION: Free MBP in nasal mucus can be used as a biomarker to diagnose CRS. The MBP ELISA represents the first immunologically-based test to potentially distinguish CRS from the eosinophilic inflammation in allergic rhinitis.

Immunologic response to fungus is not universally associated with chronic rhinosinusitis.

In the December 2009 issue of this journal, Orlandi et al presented a study in which peripheral blood mononuclear cells (PBMCs) from chronic rhinosinusitis (CRS) patients (5 from Texas, 5 from Utah) and seven nonhealthy controls were stimulated with fungal extracts. Despite the small numbers, they confirmed important aspects of previous studies: 1) CRS patients' PBMCs react to certain fungal stimuli by producing significantly (P < 0.05) higher amounts of interleukin (IL)-5 and IL-13 when compared to controls; 2) CRS patients have an enhanced humoral response (significantly elevated immunoglobulin [Ig] G levels to Alternaria); and 3) CRS patients react independently from an IgE-mediated allergy, as evidenced by that fact that nonallergic CRS patients also produced IL-5 in response to fungal stimuli. Unfortunately, the authors chose not to highlight their positive results. They emphasized what they failed to demonstrate, specifically an immune response to fungi above a certain threshold in some patients (Utah) with milder CRS. However, these results are potentially explained by the different methods used, and care should be applied when interpreting their results.

Diagnosis and treatment of chronic rhinosinusitis: focus on intranasal Amphotericin B.

Chronic rhinosinusitis (CRS) is a chronic disease that affects 14.2% of the US adult population. Despite being widespread, little is known about the etiology of CRS. Treatment has been symptomatic and focused on relieving symptoms. Recent investigations into causes of CRS have revealed that most CRS patients have an eosinophilic infiltration of their nasal tissue (mucosa), regardless of atopy and elevated immunoglobulin E levels. Although fungi are ubiquitous and in the nasal mucus of both healthy people and patients, it is only in the patients that the eosinophils (part of the inflammatory response) are found. Fungi in the nasal mucus are harmless, yet in CRS patients these same fungi stimulate an inflammatory response, inducing the eosinophils to leave the blood vessels and enter the nasal and sinus tissue and ultimately enter the nasal airway mucus. In the nasal mucus these eosinophils attack the fungi and destroy the fungi by the release of a toxic substance called major basic protein (MBP) from the granules in the eosinophils. This degranulation and release of the toxic MBP not only destroys fungi, but also produces collateral damage injuring the nasal and sinus mucosal lining tissue. The injury to the mucosal lining makes the nasal and sinus mucosa susceptible to penetration and potential infection by bacteria. When this tissue inflammation and damage is persistent and prolonged we call it CRS. The diagnosis of CRS is based largely on symptomatic criteria, with anterior rhinoscopy or endoscopy, and, if there is any doubt about the diagnosis, computed tomography imaging is employed to confirm the presence of diseased sinus mucosa. Treatment of CRS, whether medical (intranasal corticosteroids, saline irrigations) or surgical, is aimed at decreasing inflammation and obstruction in the sinonasal passages. Antibiotics, although commonly used in CRS, should not be administered unless there is suspicion of an acute bacterial infection. The theory behind the fungal and eosinophilic etiology of CRS has led to use of an antifungal compound, intranasal Amphotericin B. In clinical studies, topical irrigation with Amphotericin B has been shown to be both a safe and effective treatment for CRS.

An alternative method of middle vault reconstruction.

Surgery of the nasal valves is a challenging aspect of rhinoplasty surgery. The middle nasal vault assumes an important role in certain aspects of nasal valve collapse. Techniques that address pathologies of the middle vault include the placement of spreader grafts and the butterfly graft. We present an alternative technique of middle vault reconstruction that allows simultaneous repair of nasal valve collapse and creation of a smooth dorsal profile. The surgical technique is described in detail and representative cases are discussed.

Effects of the nasal muscles on the nasal airway.

BACKGROUND: The nasal muscles and their function are not clearly defined. The nasal muscles generally are thought to act synergistically to produce mimetic motion and affect the nasal airway. We proposed direct examination of the effects of the nasal muscles on the nasal airway. METHODS: Rhinomanometry was performed on volunteers. After paralysis of the nasal muscles with lidocaine, rhinomanometry was performed again to measure nasal airway function with the patient at rest and attempting to flare his/her nostrils. Each patient's rhinomanometric results (at rest and attempting to flare the nostrils) taken before injection of lidocaine served as the control for comparison of his/her results postinjection. The structural tension of the ala at rest and with active flaring of the nostril was measured also, and the results pre- and postparalysis with lidocaine were compared. RESULTS: The data from both the stiffness (structural tension) and the airflow portions, taken together, support the following conclusions. First, the paralysis was significant, although not complete. Clinical and stiffness data supported complete paralysis. Airflow data, which we think most sensitive, support a statistically significant affect of the injection, although incomplete paralysis. CONCLUSION: All of the evidence supports an important role for the nasal muscles when actively used to increase nasal airflow. Second, the majority of the evidence supports an important resting nasal muscle tension that opens the nasal airway.

Striking deposition of toxic eosinophil major basic protein in mucus: implications for chronic rhinosinusitis.

BACKGROUND: The mechanisms by which eosinophilic inflammation damages the epithelium and contributes to recurrent acute exacerbations in chronic rhinosinusitis (CRS) have not been fully elucidated. OBJECTIVE: We tested the hypotheses that eosinophils deposit toxic major basic protein (MBP) in the mucus and that MBP reaches concentrations able to damage the sinonasal epithelium. METHODS: Tissue specimens with mucus attached to the tissue were carefully collected from 22 patients with CRS and examined by using immunofluorescence staining for MBP. This immunofluorescence was digitally analyzed to determine the area covered by MBP and the intensity of the staining (estimating MBP concentration). Levels of MBP in extracts from nasal mucus were quantitated by means of RIA. RESULTS: Heterogeneous eosinophilia was evident within tissue and mucus specimens. All tissue specimens showed intact eosinophils, but diffuse extracellular MBP deposition, as a marker of eosinophil degranulation, was rare. In contrast, all mucus specimens showed diffuse MBP throughout and abundant diffuse extracellular MBP deposition within clusters of eosinophils. Digitized analyses of MBP immunofluorescence revealed increased area coverage (P < .0001) in mucus compared with that seen in tissue. Estimated concentrations of MBP within the clusters suggested toxic levels. MBP concentrations in mucus extract reached 11.7 microg/mL; MBP was not detectable in healthy control subjects. CONCLUSION: In patients with CRS, eosinophils form clusters in the mucus where they release MBP, which is diffusely deposited on the epithelium, a process not observed in the tissue. Estimated MBP levels far exceed those needed to damage epithelium from the luminal side and could predispose patients with CRS to secondary bacterial infections.

New paradigm for the roles of fungi and eosinophils in chronic rhinosinusitis.

PURPOSE OF REVIEW: Chronic rhinosinusitis represents a challenge with its poorly understood pathophysiology and limited treatment options. Potential roles of fungi and eosinophils in the etiology and pathophysiology of chronic rhinosinusitis are summarized. RECENT FINDINGS: Previously, the fungal role in chronic rhinosinusitis was limited to the rare subgroup, allergic fungal rhinosinusitis. Critical examination of earlier diagnostic criteria for allergic fungal rhinosinusitis reveals limitations. By using updated diagnostic standards and novel sensitive techniques to detect fungi, a higher number of patients can now be diagnosed with fungal rhinosinusitis. A novel non-IgE-mediated immunologic mechanism in chronic rhinosinusitis patients links the predominant eosinophilic inflammation to certain fungi. Overall, these new findings have implications for surgical and medical approaches, including anti-inflammatory and antifungal medications. SUMMARY: Several classification schemes and diagnostic criteria describe chronic rhinosinusitis and make comparisons difficult. Preselection of patient groups within the chronic rhinosinusitis population and the lack of sensitive diagnostic techniques have prevented a full understanding of the syndrome complex of chronic rhinosinusitis. New results suggest a broader role for fungi in the pathophysiology of chronic rhinosinusitis, linking the eosinophilic inflammation to the presence of certain molds in the nasal and paranasal cavities. Although fungi are commonly found in nearly everyone, only chronic rhinosinusitis patients respond to them with an eosinophilic inflammation. These findings support a shift in the etiologic understanding of chronic rhinosinusitis away from a bacteriologic infectious pathogenesis to a fungal-driven inflammatory pathophysiology. Herein, the authors review earlier studies and describe an updated view on an old paradigm.

Reconstruction of anterior nasal septum: back-to-back autogenous ear cartilage graft.

OBJECTIVES/HYPOTHESIS: The ideal material for reconstructing the nasal septum in the deficient nose has not been found. Since 1986, the authors have used autogenous cartilage from the cavum conchae to successfully correct the anterior septum and the associated cartilaginous saddle. The long-term results in 26 patients with a destroyed septum and a saddle nose are reported. STUDY DESIGN: Retrospective study. METHODS: The mean age of the patients at surgery was 40.2 years, and the mean number of previous nasal procedures was 1.6. Because 11 patients had septal perforations and insufficient septal cartilage or bone, ear cartilage grafts from the cavum conchae were harvested through an anterolateral approach. A special incision was used to divide the concave ear cartilage while preserving the posterior perichondrium. This produced a stable, balanced back-to-back graft. The graft was 2.5 to 3 cm long, long enough to allow reconstruction of the anterior septum and to correct part of the saddle nose deformity. The rest of the conchal cartilage was used to fill the remaining cartilaginous saddle. Follow-up investigations included photographs and visual analogue scales of the patients' symptoms and satisfaction. RESULTS: After a mean interval of 36.7 +/- 22.3 months, the back-to-back grafts showed no macroscopic signs of resorption. Graft position and shape remained intact after transplantation. All noses were adequately projected and mobile. All patients but one were satisfied with the functional and esthetic result. With a score of 4 representing the level of satisfaction as "very good," the mean score of the patients was 3.2 +/- 0.79. The saddle of the nose completely disappeared in 65.4% of patients, was minimally visible in 23.1%, and was slightly present in 11.5%. Nasal breathing improved considerably in 21 patients, remained the same in 4 patients, and worsened in 1 patient. The mean score of all patients for nasal breathing was 7.3 +/- 1.87 on a visual analogue scale of 0 to 10, with 10 representing satisfaction as "very good". CONCLUSION: The back-to-back autogenous ear cartilage graft is a viable, stable, and balanced graft for functional and aesthetic reconstruction of the anterior nasal septum and cartilaginous saddle deformity in patients with a severely traumatized and deficient septum.

Computed tomography for constructing custom nasal septal buttons.

OBJECTIVE: To determine the efficacy of computed tomography in creating custom nasal septal buttons. DESIGN: Retrospective chart review and telephone follow-up. SETTING: Tertiary care referral center. SUBJECTS: Ninety-five patients with symptomatic septal perforations repaired with custom Silastic septal buttons fashioned from reformatted computed tomographic images. Follow-up greater than 1 month was obtained in 74 patients (range, 1 month to 17 years; mean, 44.6 months). INTERVENTIONS: Custom septal buttons were placed intranasally under local or general anesthesia. MAIN OUTCOME MEASURES: Patients were evaluated for resolution of preoperative symptoms related to the septal perforation, new symptoms related to the button, and duration of button retention. RESULTS: The average perforation was 2.6 cm in diameter (range, 6 mm to 6.0 cm). Nine buttons (12%) came out unexpectedly. Nine buttons were removed because of patient intolerance, and 14 buttons were lost or removed after 5 years, longer than the projected button life span. Excluding buttons that were removed because of patient intolerance, 56 (86%) of 65 buttons were in place for longer than 5 years or at the most recent follow-up. Most patients experienced improved breathing (60%) and a considerable reduction in epistaxis (77%) and nasal crusting (59%). CONCLUSION: Custom septal buttons created using computed tomography are effective in relieving symptoms from large septal perforations.

Features of airway remodeling and eosinophilic inflammation in chronic rhinosinusitis: is the histopathology similar to asthma?

BACKGROUND: Asthma and chronic rhinosinusitis (CRS) coexist clinically in >50% of patients with CRS. Although epithelial damage and basement membrane thickening are well-known features of airway remodeling in asthma, they have not been described in CRS. OBJECTIVE: In this study, we tested the hypothesis that histopathologic features of asthma, namely, the chronic eosinophilic inflammation, epithelial damage, and basement membrane thickening of the airway mucosa, are also present in sinonasal specimens from patients with CRS. METHODS: We examined histologic specimens from 22 randomly selected patients with refractory CRS undergoing endoscopic sinus surgery and 4 healthy control subjects. The shedding of the epithelium and basement membrane thickening were evaluated by 3 independent observers' scores of hematoxylin-and-eosin staining. Eosinophilic inflammation was monitored with immunohistochemistry for eosinophil major basic protein. A novel, computerized method objectively analyzed confocal microscopic images of major basic protein immunofluorescence to determine areas with the least and most inflammation per specimen. RESULTS: Specimens from all patients with CRS (22/22) revealed epithelial damage (shedding) and basement membrane thickening. Strikingly heterogeneous eosinophilic inflammation, which did not differ between allergic and nonallergic patients, was detected in all patients with CRS and was absent in all healthy control subjects. CONCLUSION: The histopathologic findings of asthma, namely, heterogeneous eosinophilic inflammation and features of airway remodeling, are also present in CRS. These findings, coupled with the common clinical coexistence of both diseases, suggest that the same pathologic disease process is manifest as CRS in the sinonasal tissue and as asthma in the lower airway.

A grading system for nasal dorsal deformities.

There is no uniform grading system for nasal dorsal deformities currently in general use among surgeons who perform rhinoplasty. Given the popularity of this procedure among both the general public and surgeons, it is time that there was a uniform system describing dorsal deformities. Such a system has value in the education of students of rhinology and cosmetic nasal surgery. We have developed one such system, and applied it to 100 cases. In all cases it accurately describes the major pathological conditions of the dorsum, if present, as noted on physical examination. We have found application of this system to be facile.

The chemotactic behavior of eosinophils in patients with chronic rhinosinusitis.

OBJECTIVE: To characterize peripheral eosinophil migration in patients with chronic rhinosinusitis in the presence of nasal mucin and nasal tissue extracts. STUDY DESIGN: Prospective, controlled, ex-vivo. METHODS: Peripheral blood eosinophils, nasal mucin, and nasal tissue were harvested at the time of sinus surgery in 10 patients, as well as obtained in 10 healthy control subjects. Extracts were prepared from nasal mucin and nasal tissue. A modified Boyden chamber was used to study eosinophil migration from both patients and healthy control subjects in the presence of both extracts. RESULTS: Patients with chronic rhinosinusitis and all healthy control subjects demonstrated a concentration-dependent increased migration of eosinophils in the presence of both nasal mucin and nasal tissue extracts. The percentage of migration was consistently higher for eosinophils from patients with chronic rhinosinusitis compared with control subjects. The difference attained statistical significance in the presence of 50% tissue extract (median percentage of migration, 23.3% vs. 7.8% [ P=.033]). CONCLUSIONS: Nasal mucin and nasal tissue in chronic rhinosinusitis contains chemoattractants, which can induce active eosinophil migration. The eosinophil migration from patients with chronic rhinosinusitis was consistently higher compared with eosinophils from healthy control subjects. Because the eosinophils were obtained from the peripheral blood, this finding suggests activation of eosinophils in the systemic circulation in chronic rhinosinusitis.

Intranasal antifungal treatment in 51 patients with chronic rhinosinusitis.

BACKGROUND: Chronic rhinosinusitis (CRS) is the most common chronic disease that is frequently refractory to treatment. OBJECTIVE: We sought to establish the safety and demonstrate the clinical efficacy of intranasal antifungal drug therapy in patients with CRS in a pilot trial. METHODS: A prospective open-label trial used amphotericin B as a medical treatment in 51 randomly selected patients with CRS. The antifungal agent was applied intranasally as 20 mL of a 100 microg/mL solution twice daily. The outcome was measured by using their symptoms and by using an endoscopic scoring system in all patients. In addition, pretreatment and posttreatment coronal computed tomographic scans of the nose and sinuses were available for evaluation in 13 patients. RESULTS: By using amphotericin B, improvement of sinusitis symptoms was observed in 38 (75%) of 51 patients. Endoscopically, 18 (35%) of 51 patients became disease free, and an additional 20 (39%) of 51 had improvement of at least one stage (P <.001). No effect was seen in 13 (25%) of 51 patients. The available computed tomographic scans before and after treatment demonstrated a significant reduction in the inflammatory mucosa thickening that had occluded the paranasal sinuses (P <.0001 in maxillary sinus). CONCLUSION: This open-label pilot trial demonstrates that direct mucoadministration of an antifungal drug appears to be both safe and effective in the treatment of patients with CRS. Therefore controlled and blinded trials are indicated to clarify the novel role of intranasal antifungal drugs in the treatment of CRS.

Detection of fungal organisms in eosinophilic mucin using a fluorescein-labeled chitin-specific binding protein.

BACKGROUND: The ability to identify fungal hyphae in patients with chronic rhinosinusitis (CRS) has been inconsistent. A new fluorescein-labeled staining method targets chitin found in fungal cell walls. OBJECTIVE: We hypothesize that this method would be able to more consistently detect fungi within the mucin of CRS patients. METHODS: Fifty-four consecutive CRS surgical patients were evaluated. After ensuring sensitivity and specificity of this new method, all specimens were stained with either fluorescein-labeled chitinase or Grocott methanamine silver stain for comparison. RESULTS: All 54 specimens contained eosinophilic mucin on hematoxylin and eosin staining. One or more fungal hyphae could be visualized within the mucin of 54 (100%) of 54 specimens stained using the fluorescein-labeled chitinase. Only 41 (76%) of 54 of the specimens stained with the Grocott methanamine silver stain technique demonstrated fungi. CONCLUSION: The fluorescein-labeled chitinase-staining technique has greater sensitivity in detecting fungal organisms within eosinophilic mucin. Fungal organisms are present in the mucin of CRS patients.