Double Blinded Randomized Controlled Trial Comparing Budesonide and Saline Nasal Rinses in the Post-operative Management of Chronic Rhinosinusitis.

Post-operative management of chronic rhinosinusitis is very crucial for outcomes following surgery, Normal saline nasal irrigation and steroid spray form the standard treatment of care in this period. However nasal irrigation may not be adequate and spray is usually started after 2 weeks of surgery which in any case does not deliver optimum dosage of drug to the paranasal sinus mucosa. Budesonide nasal irrigation in a high-volume low-pressure system could be the solution for a better outcome. A double blinded randomized control trial with 88 patients in 2 groups of 44 each received normal saline or Budesonide nasal irrigation (0.5 mg in 200 ml) twice daily. Patients were followed up at 2 weeks post-operatively and 3 months, a SNOT 22 and Lund Kennedy Endoscopic scores were assessed for subjective and objective assessment. Subset analysis of only CRS patients (55) were done, and results presented. Patient reported subjective score at 3 months post operatively, SNOT22 was significantly (p < 0.0001) improved with the use of Budesonide irrigation (26.69 ± 2.92) as compared to Normal saline (30.54 ± 2.81) and objective assessment score, LKES was significantly (p = 0.0031) better in Budesonide group (4.06 + 0.74) in comparison to Normal saline in the saline (4.50 + 0.67) respectively. The mean scores 3 months post op visit was significantly lower for both subjective SNOT (p < 0.001) and objective score LKES (p < 0.0001) in Budesonide groups. Budesonide nasal irrigation with positive pressure high volume device has better patient benefits and wound healing when compared to normal saline irrigation in the post-operative management of chronic rhinosinusitis.

68 Ga-Citrate PET/CT Imaging in the Diagnosis of Skull Base Osteomyelitis and Its Usefulness in the Assessment of Treatment Response.

PURPOSE: 68 Ga-citrate PET/CT imaging in the diagnosis of skull base osteomyelitis (SBO) and its usefulness in the assessment of treatment response. METHODS: Eighteen patients underwent 68 Ga-citrate PET/CT scans for suspected SBO for diagnosis/assessment of treatment response. RESULTS: Of 18 patients, 16 patients had a positive study for SBO, and 2 patients had a negative study. Scan findings were correlated with clinical, biochemical, microbiological, and radiological parameters. CONCLUSION: 68 Ga-citrate PET/CT is a promising tool in the diagnosis and management of skull base osteomyelitis.

Clinico-Radiological Evaluation for Longitudinal Assessment in Central Skull Base Osteomyelitis: Proposal of Novel Scoring System.

This study aims to evaluate clinical, radiological and laboratory parameters for longitudinal assessment and prognostication in central skull base osteomyelitis (CSBO). Novel radiological score and cranial nerve assessment score (CNAS) have been proposed and analysed along with pain score (VAS), ESR, CRP, WBC count, and HbA1c for utility in disease-monitoring and predicting outcome in CSBO. CSBO cases managed in a tertiary care centre from January 2018 to November 2020, with a minimum follow-up of 6 months were included. The parameters were recorded at presentation, 3-month, 6-month postoperative follow-up, and at completion of therapy, for statistical analysis. Significant positive correlation was found amongst pain score, CNAS, radiological score, ESR, and CRP at different timelines. On longitudinal assessment, there was a statistically significant reduction in above-mentioned parameters, in the cases who recovered. Those with initial radiological score < 30, pain score ≤ 7, and CNAS < 10 showed early clinical improvement, required shorter duration of antimicrobial therapy, and exhibited higher probability of becoming disease-free at an earlier time, compared to those presenting with higher scores. We propose the use of pain score, a novel cranial nerve assessment score, and a novel radiological score for longitudinal assessment in CSBO. The trend in these parameters along with ESR and CRP are useful to monitor the disease process. The initial assessment scores can predict duration of antimicrobial therapy and probability of early recovery. WBC count and HbA1c were neither useful for disease-monitoring nor predicting outcome.

Tension Pneumocephalus: A Potentially Fatal Complication of Expanded Endoscopic Endonasal Approach.

While some volume of pneumocephalus occurs following any surgery entailing dural breach, tension pneumocephalus (TP) is a rare complication of endoscopic endonasal surgery described in less than 1% cases including expanded endoscopic endonasal approaches (EEEA). It is a neurosurgical emergency warranting urgent decompression. Two cases, who developed TP following EEEA are presented. One had sinonasal malignancy (adenoid cystic carcinoma) eroding the anterior skull-base (T4N0M0) and the other was a large olfactory groove meningioma. TP was heralded in both by sudden deterioration in neurological status. Both cases underwent bifrontal craniotomy for decompression with simultaneous skull-base repair incorporating a vascularised pericranial flap. Brief literature review regarding the pathophysiology, contributing factors, diagnosis, management, and prevention of TP following EEEA is presented. TP, a life-threatening neurosurgical emergency, warrants meticulous precautions for its prevention, and vigilant postoperative monitoring for early detection. Urgent decompression with thorough skull-base repair is imperative to prevent complications.

A novel nasoseptal flap harvesting technique in revision expanded endoscopic transsphenoidal approaches.

OBJECTIVES: To describe the technique of harvesting the nasoseptal flap (NSF) in revision-expanded endoscopic approaches (EEA). STUDY DESIGN: We retrospectively analyzed four cases of endoscopic skull base reconstruction (ESBR) following revision EEA done for pituitary adenoma recurrence. The presence of an intact mucoperiosteum between the nasal septum and the roof of the choana as judged on a preoperative endoscopic and radiological assessment was considered to be sufficient for the presence of a viable pedicle. By strategic placement of the incisions, the entire bilateral posterior nasal septal mucoperiosteum was raised in the NSF containing the remnant vascular pedicle. ESBR was performed with multilayer grafting of the dural defect, and the NSF was placed onto the bony margins of the defect. RESULTS: All patients had successful skull base reconstruction with the NSF raised by this technique as none of them developed postoperative cerebrospinal fluid leak. CONCLUSION: Though the number of patients in this study is small, we would like to present the concept of harvesting the NSF in revision surgery, wherein neither measuring the surface area of the pedicle nor the acoustic Doppler assessment of the pedicle is required.

Skull Base Osteomyelitis Caused by an Elegant Fungus.

Malignant otitIs externa (skull base osteomyelitis) is predominantly caused by bacteria while fungal etiology is rare. We report a middle aged diabetic gentleman who succumbed to invasive skull base infection due to Apophysomyces elegans a fungus belonging to Zygomycetes which causes only skin and soft tissue infections. Mortality and invasive infections due to this genus is rarely reported, especially in the ear.

Missed intranasal wooden foreign bodies on computed tomography.

We report a case of post traumatic impacted intranasal wooden foreign body in a 16 year old boy, which was undetected on Computed Tomography in the acute stage. Intranasal wooden foreign body may be missed on CT in the acute stage because of apparent air attenuation of the foreign body and lack of contrast with the surrounding intranasal air. Radiologists need to be aware of the CT imaging appearances of wood in various stages for early detection and management.