Effects of intrapolyp steroid injection on intraocular pressure and recurrent polyp treatment.

PURPOSE: To examine the effects of intrapolyp triamcinolone acetonide (TA) injections on intraocular pressure (IOP) and recurrence of nasal polyps after endoscopic sinus surgery. PATIENTS AND METHODS: This was a prospective, randomized, double-blind, placebo-controlled study. Patients were randomized into either the TA injection group (Group I, 20 mg/ml, 2 mL) or the placebo normal saline injection group (group II, 2 mL). There were a total of five study visits: one baseline visit and one at 2, 4, 8, and 12 w after the injection. The primary safe outcome was the change in IOP between two groups at 4 w. The secondary safe outcome was the IOP at each visit and proportion of patients having IOP above 21 mmHg at 4 and 8 w. Changes in the nasal polyp size were measured between two groups at each visit. RESULTS: A total of 43 consenting participants completed this study (22 in group I and 21 in group II). The mean IOP elevation in both eyes was not significantly different between the groups (p > 0.05) and was not over 2 mmHg at the 4-w mark. There was also no significant difference in the proportion of patients having IOP above 21 mmHg at 4 and 8 w between the groups (p > 0.05). However, there was a significant difference in the change in polyp size until 8 w between both groups (p < 0.01). CONCLUSIONS: Intrapolyp TA injection is a safe and effective method for the management of recurrent polyps after endoscopic sinus surgery.

A novel surgical technique to correct caudal and high dorsal septal deviations: L-shape cutting and suturing on the septal L-strut (L-septoplasty).

OBJECTIVES: In general, deviation of the L-strut of the nasal septum is more challenging to correct than the middle and has less favorable results. This study aimed to develop a technique to correct the L-strut while preserving nasal support effectively and introduce the L-septoplasty technique and its effects. METHODS: Patients with caudal and high dorsal septal deviations who underwent the L-septoplasty technique were retrospectively analyzed. Preoperative and three-month postoperative comparative assessments included the Nasal Obstruction Symptom Evaluation (NOSE) scale and minimal cross-sectional area (MCA). RESULTS: Thirty patients seen at a tertiary care center were included. NOSE scale scores improved from 47.2 to 13.6, which was statistically significant (P < .001). MCA increased from 0.43 cm2 to 0.74 cm2 (P < .001). During the 3-month follow-up period, deviation correction was well maintained in all patients, and no surgical complications, such as saddle nose deformity, occurred. CONCLUSION: The L-septoplasty technique is effective in simultaneously correcting caudal and high dorsal septal deviations without any complications. LEVEL OF EVIDENCE: 4.

Sino-Cutaneous Fistula After Using Medpor Implant in Orbital Blowout Fracture.

In surgical repair of orbital fracture, implant materials play an important role in restoring the functional and anatomic structure of the orbit. Alloplastic implant materials are widely used for this surgery, but they have the risk of complications such as infections, pain, and extrusion. Because they are artificial implants, infection can occur more than autologous implants and is the most challenging problem to manage. Sino-cutaneous fistula is a rare complication of chronic sinusitis and it can be caused by this implant materials. The authors report a case of formation of sino-cutaneous fistula after using Medpor (Stryker Co, MI) implant in orbital blowout fracture repair.

Effective Continuous Positive Airway Pressure Changes Related to Sleep Stage and Body Position in Obstructive Sleep Apnea during Upward and Downward Titration: An Experimental Study.

BACKGROUND AND PURPOSE: The aim of this study was to determine how the sleep stage and body position influence the effective pressure (Peff) in standard upward titration and experimental downward titration. METHODS: This study applied successful manual titration of continuous positive airway pressure over 3 hours [including at least 15 min in supine rapid eye movement (REM) sleep] followed by consecutive downward titration for at least 1 hour to 22 patients with moderate-to-severe obstructive sleep apnea. We analyzed baseline polysomnography variables and compared the effective pressures (Peff1upward and Peff2downward) between non-REM and REM sleep and between supine and lateral positions using the paired t-test or Wilcoxon signed-rank test. RESULTS: During upward titration, Peff1 increased during REM sleep compared to non-REM sleep [9.5±2.9 vs. 8.9±2.7 cm H2O (mean±SD), ΔPeff1REM-non-REM=0.6±1.1 cm H2O; p=0.024]. During downward titration, Peff2 was higher in a supine than a lateral position (7.3±1.7 vs. 4.8±1.5 cm H2O, ΔPeff2supine-lateral=2.5±1.3 cm H2O; p=0.068). When comparing both upward and downward titration conditions, we found that Peff2 was significantly lower than Peff1 in all sleep stages, especially during REM sleep (Peff1REM vs. Peff2REM=9.5±2.9 vs. 7.4±3.3 cm H2O) with an overall difference of 2.1±1.7 cm H2O (p<0.001). Peff in supine sleep decreased from 9.4±3.0 cm H2O (Peff1supine) to 7.6±3.3 cm H2O (Peff2supine), with an overall difference of 1.8±1.6 cm H2O (p<0.001). CONCLUSIONS: This study has revealed that the collapsibility of the upper airway is influenced by sleep stage and body position. After achieving an initial Peff1, a lower pressure was acceptable to maintain airway patency during the rest of the sleep. The observed pressure decrease may support the use of an automated titration device that integrates real-time positional and sleep-stage factors, and the use of a lower pressure may improve fixed-pressure-related intolerance.

MR imaging findings of metastatic hepatocellular carcinoma in the nasal cavity: a rare site of spread.

We here report an extremely rare case of metastatic hepatocellular carcinoma to the nasal cavity only with MRI scan including diffusion-weighted imaging and a brief review of previous literature case reports.

Radiation Dose Reduction in Paranasal Sinus CT: With Feasibility of Iterative Reconstruction Technique.

OBJECTIVES: To (1) compare the radiation dose of low-dose computed tomography (CT) to that of standard-dose CT, (2) determine the minimum optimal radiation dose for use in patients who need endoscopic sinus surgery, and (3) assess the reliability of iterative model reconstruction. STUDY DESIGN: Prospective single-institution study. SETTING: Tertiary care center. SUBJECTS AND METHODS: We recruited 48 adults with medically refractory sinusitis. Each patient underwent 4 scans with different CT parameters: 120 kV and 100 mAs (standard dose), 100 kV and 40 mAs (low dose), 100 kV and 20 mAs (very low dose), and 100 kV and 10 mAs (ultra-low dose). All CT scans were reconstructed via filtered back-projection, and ultra-low dose scans were additionally reconstructed through iterative model reconstruction. Radiation dose, image quality, and diagnostic performance were compared among the scans. RESULTS: Radiation doses decreased to 6% (ultra-low dose), 12% (very low dose), and 22% (low dose) of the standard-dose CT. The image quality of low-dose CT was similar to that of standard-dose CT. Ultra-low-dose CT with iterative model reconstruction was inferior to standard-dose CT for identifying anatomic structures, except for the optic nerve. All CT scans had 100% agreement for diagnosing rhinosinusitis. CONCLUSIONS: With low-dose CT, the radiation dose can be decreased to 22% of that of standard-dose CT without affecting the image quality. Low-dose CT can be considered the minimum optimal radiation for patients who need surgery. Iterative model reconstruction is not useful for assessing the anatomic details of the paranasal sinus on CT.

Impact of adenotonsillectomy on nocturnal enuresis in children with sleep-disordered breathing: A prospective study.

OBJECTIVES/HYPOTHESIS: To investigate the relationship between sleep-disordered breathing (SDB) and nocturnal enuresis (NE) in children and to prospectively evaluate the effectiveness of adenotonsillectomy on resolving enuresis in indicated SDB patients with NE. METHODS: We prospectively collected data from 183 children (121 males, mean age 8.17 ± 2.84 years) who underwent adenotonsillectomy to treat SDB between July 2011 and July 2013, and analyzed the prevalence of NE. Before and 3 months after surgery, all parents were requested to answer a self-reported SDB scale questionnaire (22 questions, 0-22 points) and a NE questionnaire (episodes of enuresis per month). Paired t test, Student t test, and Chi-square test were used to analyze the data. RESULTS: Overall prevalence of NE was 9.3% (17 patients) preoperatively and 1.5% postoperatively (four patients). After adenotonsillectomy, prevalence of NE and the mean SDB scale were significantly decreased (both P values < 0.001). After adenotonsillectomy, 13 of the 17 NE patients (76.5%) showed complete resolution. There was significantly higher prevalence of NE in patients with obstructive sleep apnea (OSA) than those without OSA (13.1%, 14 of 107 vs. 3.9%, 3 of 76; P = 0.036). CONCLUSION: There is strong association between NE and SDB, and adenotonsillectomy can markedly improve enuresis in the majority of children with NE and SDB. LEVELS OF EVIDENCE: 4. Laryngoscope, 126:1241-1245, 2016.

Comparative Study for Efficacy and Safety of Adenoidectomy according to the Surgical Method: A Prospective Multicenter Study.

BACKGROUND/OBJECTIVE: There have been several operative techniques for adenoidectomy and their efficacy and morbidity are different according to the technique. This prospective multicenter study was aimed to compare the efficacy and morbidity of coblation adenoidectomy (CA) with those of power-assisted adenoidectomy. STUDY DESIGN: Prospective multi-institutional study. METHODS: Children who underwent CA, power-assisted adenoidectomy with cauterization (PAA+C) or without cauterization (PAA-C) due to adenoid hypertrophy were enrolled from 13 hospitals between July 2013 and June 2014. Mean operation time, degree of intraoperative bleeding and postoperative bleeding rate were evaluated. RESULTS: A total of 388 children (mean age ± standard deviation = 6.6 ± 2.5 years; 245 males and 143 females) were included. According to the adenoidectomy technique, the children were classified into 3 groups: (1) CA (n = 116); (2) PAA+C (n = 153); and (3) PAA-C (n = 119). Significant differences were not found in age and sex among three groups. In the CA group, mean operation time was significantly shorter (P < 0.001) and degree of intraoperative bleeding was significantly less (P < 0.001) compared to PAA+C or PAA-C group. Delayed postoperative bleeding rate of PAA-C group was significantly higher than that of CA or PAA+C group (P = 0.016). CONCLUSIONS: This prospective multicenter study showed that CA was superior to PAA in terms of mean operation time and degree of intraoperative bleeding.

Dehiscence of the infraorbital canal with the maxillary antral empyema: a new cause of facial pain.

The infraorbital nerve is the largest cutaneous branch of the maxillary divisions of the trigeminal nerve. It may produce a bony ridge on the antral roof but usually goes through within the maxillary bone as a discrete canal. Rarely, it could be partially or completely dehiscent, lying submucosally on the antral roof as in this case. We describe a case of longstanding facial pain because of dehiscence of the infraorbital canal associated with the maxillary antral empyema. Endoscopic sinus surgery was successful in relieving the symptom.

Dexamethasone Induces Apoptosis of Nasal Polyp-Derived Tissue Cultures Through JNK and p38 MAPK Activation.

OBJECTIVES: Glucocorticoids, such as dexamethasone (DEX), increase apoptosis in a variety of white cells in nasal polyps and apoptosis is an important factor in the resolution of inflammation. However, the mechanism of glucocorticoids induced apoptosis in nasal polyp remains unclear. In this study the authors evaluated which pathways were engaged in apoptosis induced by DEX in an ex vivo model of nasal polyps. METHODS: Nasal polyp tissues were cultured using an air-liquid interface method. Cultures were maintained in the absence or presence of DEX (10 or 100 µM) for 24 hours. To investigate the involvement of the apoptotic signaling pathways in nasal polyp, such as caspase cascades, Fas-FasL signaling pathway, mitochondrial pathway and p38 mitogen-activated protein kinase (MAPK)/JNK pathway, the authors performed reverse transcription-polymerase chain reaction and Western blotting. RESULTS: The expression ratios of FasL, activated form of caspase-8, caspase-9, and caspase-3 were significantly higher in DEX-treated polyps (P<0.01). In the Bcl-2 family expression, the anti-apoptotic molecules, Bcl-2 and Bcl-XL decreased, but pro-apoptotic molecules, Bax increased, and Bid and Bad were activated. In the conventional MAPKs, JNK, and the phospho-p38 MAPK were significantly higher, but phospho-extracellular signal-regulated kinase (ERK)1/2 was significantly lower in DEX-treated polyps (P<0.01). CONCLUSION: DEX induces apoptosis of nasal polyp via caspase cascades, Fas-FasL signaling pathway, mitochondrial pathway and p38 MAPK/JNK pathway.

Endoscopic reduction of orbital medial wall fracture using rotational repositioning of the fractured: lamina papyracea fragment.

Orbital fractures are frequently observed in maxillofacial trauma and can cause a wide range of functional impairments and esthetic deformities. Many approaches have been used for the repair of medial orbital wall fractures. It has been necessary to use grafts or splints in these approaches. We introduced a new technique to treat our patient with diplopia that resulted from a medial orbital fracture. In this new method that involves rotational repositioning of the fractured segment, there is no need for a graft from another location or synthetic material. This technique has several advantages compared with using synthetic materials or other types of autogenous grafts. However, the limitation of this method is that our technique cannot be applied to all cases of medial orbital wall fracture.

Effect of fibrin-coated collagen fleece (TachoComb) on pain and bleeding after adenotonsillectomy in children.

CONCLUSION: Even though the use of TachoComb does not decrease pain after tonsillectomy, it is safe and useful to reduce bleeding after tonsillectomy. OBJECTIVES: Sealing the post-tonsillectomy wound would be expected to reduce pain and bleeding by decreasing the exposure of the traumatized tissue and sensory nerves. TachoComb is a powerful topical hemostatic agent. The objectives of this study were to evaluate the effect of TachoComb on reduction of pain and bleeding after tonsillectomy. METHODS: A prospective randomized double-blind study was performed on 120 pediatric patients undergoing adenotonsillectomy. The patients were randomized into two groups: use/non-use of TachoComb. In the study group, each tonsillar bed was covered with a TachoComb strip at the end of operation. No hemostatic agents were used in the control group. After surgery, patients were monitored for pain, bleeding, oral intake, medication administration, activity, and complications using a 10-day diary. RESULTS: In all, 110 patients returned and filled in the diary. The use of TachoComb did not decrease pain, reduce the use of analgesic drugs or speed recovery to normal everyday life. Post-surgery bleeding was not experienced by any of the TachoComb patients, but occurred in five of the control patients. The result had borderline statistical significance (p < 0.1).