Fat enhanced leukocyte-platelet-rich fibrin versus fascia lata in endoscopic reconstruction of CSF leaks.

PURPOSE: The aim of this study was to use a new biological active fat enhanced leukocyte-platelet-rich fibrin membrane (L-PRF) for skull base defect reconstruction and compare its validity and reliability with the time-honored fascia lata. METHODS: This prospective study was conducted on 48 patients with spontaneous CSF leaks who were divided into 2 matched groups by stratified randomization, 24 patients in each group. In group A we performed multilayer repair using fat enhanced L-PRF membrane. In group B we used fascia lata for the multilayer repair. In both groups we enforced the repair with mucosal grafts/flaps. RESULTS: The two groups were statistically matched for age, sex, intracranial pressure, and site and size of the skull base defect. There was no statistically significant difference between the two groups regarding the outcome of the repair or recurrence of CSF leak during the first postoperative year. Meningitis occurred in one patient in group B and was successfully treated. Another patient in group B developed thigh hematoma which resolved spontaneously. CONCLUSION: The fat enhanced L-PRF membrane is a valid reliable option in repair of CSF leaks. The membrane is autologous, readily available, easily prepared, and has the advange of including stromal fat, stromal vascular fraction (SVF), and leukocyte-platelet-rich fibrin (L-PRF). The present study showed that fat enhanced L-PRF membrane is stable, non-absorbable, not liable to shrink or become necrotic, and can establish good seal of the skull base defect and further enhance the healing process. The use of the membrane also has the advantage of avoiding thigh incision and possible hematoma formation.

Nasal Reactivity After Radiofrequency Ablation of Peripheral Branches of Posterior Nasal Nerve.

Objective: Transection or ablation of the posterior nasal nerve (TRPN) has been described as an adjunctive tool to reduce the symptoms of intractable allergic rhinitis (AR). The procedure, however, requires surgical skill and carries the risk of bleeding from the sphenopalatine artery. The aim of the present study is to describe radiofrequency ablation of the peripheral branches of the posterior nasal nerves within the inferior turbinates (RAPN) as an effective easier alternative to TRPN. Methods: The procedure was performed on 24 patients with intractable AR. Nasal reactivity was tested by cold dry air (CDA) provocation before and 12 months after the radiofrequency procedure. Visual analog scale and acoustic rhinometry were used to measure the changes in nasal reactivity subjectively and objectively. Results: Worsening of nasal symptoms following CDA provocation had significantly decreased after the RAPN procedure. Likewise, postoperative decrease in nasal volumes and minimal cross-sectional areas after CDA provocation were significantly less than the corresponding preoperative values. Conclusion: RAPN effectively reduces nasal reactivity in patients with AR. The procedure is simple, minimally invasive, and can be performed under local or general anesthesia.

Traumatic cerebrospinal fluid leakage following septorhinoplasty.

Septoplasty/septorhinoplasty is a common ear, nose and throat procedure offered for those patients with deviated septum who are suffering from nasal obstruction and functional or cosmetic problems. Although it is a basic and simple procedure, it could lead to catastrophic complications including major skull base injuries which result in cerebrospinal fluid (CSF) leaks. We describe two different cases of traumatic CSF leaks following septoplasty/septorhinoplasty at two different sites. The first patient suffered a CSF leak following septoplasty and presented to Alexandria University Hospital. The leak was still active at presentation and identified as coming from a defect in the roof of the sphenoid sinus and was repaired surgically. The second patient presented 4 days after her cosmetic septorhinoplasty with a CSF leak and significant pneumocephalus. She was managed conservatively. Understanding the anatomical variations of the paranasal sinuses and implementing proper surgical techniques are crucial in preventing intracranial complications when performing either septoplasty or septorhinoplasty. A good quality computed tomography of the nose and paranasal sinuses is a valuable investigation to avoid major complications especially CSF leaks following either procedure.

Extramucosal pyriplasty without stenting for management of pyriform aperture stenosis.

PURPOSE: The current management options of congenital pyriform aperture stenosis (CNPAS) are either conservative measures awaiting further growth of the bony nasal framework or surgical intervention that focuses on bone removal from the margin of the pyriform aperture (PA) without exposure of the nasolacrimal duct (NLD) followed by stenting. Recently, CT measurements of the nasal cavity in CNPAS have shed light that the site of maximal bony obstruction corresponds to the bony buttress encasing the NLD rather than the margin of the PA as initially thought. Herein, we present an extramucosal pyriplasty technique that can be used without stenting to enlarge the PA and achieve immediate and sustained relief of nasal obstruction. METHODS: Retrospective chart review of 4 patients with radiologically confirmed CNPAS who had undergone extramucosal pyriplasty without stenting during the period from 2012 to 2016. RESULTS: Three patients were full term without any clinically detectable congenital anomaly. The fourth patient was preterm infant who needed ICU management. On computerized tomography scan, the PA width ranged from 5.8 to 7.1 mm with a mean of 6.4 mm while site of maximal stenosis ranged from 5.4 to 6.8 with a mean of 6 mm. Extramucosal pyriplasty relieved nasal obstruction and restored normal oral feeding in all patients. Postoperative follow-up endoscopy revealed an adequately patent airway with no scarring, granulation or restenosis. CONCLUSIONS: Extramucosal pyriplasty with decompression of the NLD without stenting is a treatment modality for CNPAS that provides prompt sustainable relief of nasal obstruction and avoids the drawbacks of stenting and shortcomings of the current conservative methods.

Role of bacterial biofilm in development of middle ear effusion.

Biofilms have been implicated in the development of several chronic upper respiratory tract infections. Role of bacterial biofilms has been well studied in the pathogenesis of chronic rhinosinusitis. However, its impact on development of middle ear effusion is still a matter of debate. To study the extent of surface adenoid biofilm and evaluate its role in the pathogenesis of chronic otitis media with effusion in children. The study was carried out on 40 children in Alexandria Main University Hospital between 1 and 16 years of age without sex predilection, who were divided into two groups. The first group (20 children) had otitis media with effusion associated with adenoid hypertrophy, whereas the second group (20 children) had adenoid hypertrophy without middle ear effusion. Adenoidectomy with ventilation tube insertion was done for group 1 cases, whereas, only Adenoidectomy was done for group 2 cases. The samples were processed for the detection of biofilms by scanning electron microscopy. The biofilm formation was graded according to extension. Biofilm formation was detected on all samples for group 1. Adenoids removed from patients with otitis media with effusion had higher-grade biofilm formation than the other group (P 0.0001). No correlation was found between adenoid size and biofilm formation. In pediatric population, adenoid surface biofilm formation may be involved in the pathogenesis otitis media with effusion.

Endoscopic endonasal multilayer repair of traumatic CSF rhinorrhea.

The incidence of traumatic CSF has increased in recent years due to increased incidence of road traffic accidents (RTA) as well the increasing number of endoscopic sinus surgeries (ESS). The objective of this study is to present our experience in management of traumatic CSF leaks using the endoscopic multilayer repair technique. Forty-two patients (aged 10-75 years, 30 males and 12 females) presenting with confirmed post-traumatic CSF rhinorrhea were operated upon between January 2007 and December 2013. The endoscopic multilayer technique was used in all cases. Electromagnetic navigation was used in some cases. All cases presented with intermittent watery rhinorrhea. The duration of the rhinorrhea ranged from 3 days to 1 year before repair. One case presented after 10 years from the causative trauma. Ten cases had a history of meningitis. Nine cases had more than one defect. Iatrogenic defects were larger than defects following accidental trauma. Two cases, following RTA, developed pseudo-aneurysm of internal carotid artery. Ten cases had associated pneumocephalus. The mean duration of postoperative hospitalization was 6 days (range 4-8 days). The mean follow-up duration was 31.2 +/- 11.4 months (range 16-48 months). None of our patient developed serious intra- or postoperative complications. Only one case required another surgery to repair a missed second defect. Post-traumatic CSF leaks can be successfully managed via the endonasal endoscopic route using the multilayer repair technique. It is important to look for multiple defects in these cases. CT angiography is recommended for traumatic leaks involving the lateral wall of the sphenoid sinus to diagnose or exclude the development of pseudo-aneurysm of the internal carotid artery.

Effect of passive smoking on the ultrastructure of the nasal mucosa in children.

OBJECTIVES/HYPOTHESIS: Passive exposure to cigarette smoke has been implicated in a number of respiratory childhood disorders. Most studies concerning smoking were directed to its carcinogenic effect on the lungs. However, the effects of smoking on nasal respiratory mucosa have not been widely studied. The aim of the present study was, therefore, to study the ultrastructural changes in the nasal mucosa of a pediatric population exposed to passive smoking. STUDY DESIGN: The study included 20 children between the ages of 5 and 11 years, who were scheduled for tonsillectomy and at the same time had a positive history of prolonged exposure to household passive smoke. Another 10 children with a negative household smoking history were included as a control group. All children were nonatopic and with a negative family history of allergy. None of them had adenoids or infective rhinosinusitis. METHODS: At the time of surgery, a 1-mm(3) biopsy was taken was taken from the lower border of the inferior turbinate. The specimens were processed and examined with electron microscopy RESULTS: Examination of the nasal mucosa showed several ultrastructural changes. These included patchy loss of cilia, generalized loss of cilia, squamous metaplasia, hyperplasia of goblet cells and seromucinous acini, and vascular congestion. More severe changes were observed with longer passive exposures to cigarette smoke. The study did not disclose any evidence of ongoing allergic reaction or neoplastic transformations. CONCLUSIONS: Children exposed to passive cigarette smoke may develop several structural changes in the respiratory nasal mucosa with subsequent negative effects on its ciliary activity and mucociliary function. As a result of these effects, defense mechanisms of the nose may be ruined or lost, and those children may develop persistent sinonasal infections. Exposure of these children to passive smoking for longer periods of time may also induce other significant changes that were not detected in the present study.