Surgical Experience in Pediatric Patients with Chiari-I Malformations Aged ≤18 Years.

OBJECTIVE: The objective of this study was to retrospectively study Chiari I malformation patients (<18 years) treated surgically. MATERIALS AND METHODS: Chiari I malformation patients (<18 years) treated surgically at our institute were retrospectively studied. RESULTS: During the study period between January 1999 and June 2011, fifty patients, aged ≤18 years with Chiari malformation, were treated surgically and formed the basis for this series. There were 21 female children (42%) and 29 male children (58%), with a female-to-male ratio of 1:1. At the last follow-up, oropharyngeal symptoms were improved in 33% (n = 3/9). Headache/neck/back pain improved in 69.56% of children (n = 16/23). Upper-extremity pain/weakness/numbness improved in 73.91% of children (n = 17/23). Ataxia improved in 66.66% of children (n = 4/6). Lower-limb weakness/hyperreflexia improved in 83.33% of children (n = 5/6). At follow-up, magnetic resonance imaging for patients with syrinx was available for 75% of patients (n = 30/50) and not available for 25% of patients (n = 10/40). Syrinx was diminished in size or resolved in 66.33% of patients (n = 19/30) and the remaining was same for 36.66% of patients (n = 11/30). CONCLUSIONS: The main goal of surgery is to arrest the progression of neurological deficits. Foramen magnum decompression with a lax duroplasty is the surgical procedure of choice.

Association of intracellular Staphylococcus aureus with prognosis in chronic rhinosinusitis.

BACKGROUND: Staphylococcus aureus (S. aureus) has been shown to exist within nasal epithelial cells in chronic rhinosinusitis (CRS) patients. This study investigates the localization of intracellular S. aureus (ICSA) in CRS patients, the associated histopathology changes, and their effect on long-term postoperative outcomes. METHODS: A prospective study of patients with CRS with and without polyps and control patients (n = 25, 15, and 8, respectively) undergoing endoscopic sinus surgery was performed. Validated patient reported symptom scores and objective endoscopic scores were collected preoperatively and 12 months postoperatively. Mucosal tissue samples were collected and examined for the presence of ICSA using immunohistochemical analysis. Tissue also underwent routine hematoxylin and eosin and Sirius Red staining to evaluate the inflammatory cell load and extent of fibrosis. RESULTS: ICSA appeared to localize to the perinuclear region of the pseudostratified columnar respiratory epithelium. ICSA was more prevalent in CRS without nasal polyps (CRSsNP) than in CRS with nasal polyps (CRSwNP) or controls (80% vs 56% vs 38%, respectively). ICSA positive status did not appear to influence symptom or endoscopic scores at the time of surgery nor 12 months postoperatively. Lymphocytes and total inflammatory cells were significantly increased in ICSA(+) group than ICSA(-) groups (36.4 vs 22.4 cells/area and 53.8 vs 29.1 cells/area, respectively). There was no difference found in fibrosis. CONCLUSION: This study indicated that ICSA was most prevalent in CRSsNP patients and was associated with increased lymphocytia and total inflammatory cells but not with worse symptomatology, endoscopy results, or basement membrane (BM) thickening.

Efficacy of NVC-422 against Staphylococcus aureus biofilms in a sheep biofilm model of sinusitis.

BACKGROUND: Bacterial biofilms are a major obstacle in management of recalcitrant chronic rhinosinusitis. NVC-422 is a potent, fast-acting, broad-spectrum, nonantibiotic, antimicrobial with a new mechanism of action effective against biofilm bacteria in in vitro conditions. The aim of this study was to investigate the safety and efficacy of NVC-422 as local antibiofilm treatment in a sheep model of rhinosinusitis. METHODS: After accessing and occluding frontal sinus ostia in 24 merino sheep via staged endoscopic procedures, S. aureus clinical isolate was instilled in frontal sinuses. Following biofilm formation, ostial obstruction was removed and sinuses irrigated with 0.1% and 0.5% NVC-422 in 5 mM acetate isotonic saline at pH 4.0. Sheep were monitored for adverse effects and euthanized 24 hours after treatment. Frontal sinuses were assessed for infection and changes in mucosa after the treatment. S. aureus biofilms were identified with Baclight-confocal scanning microscopy protocol and the biofilm biomass assayed by applying the COMSTAT2 program to recorded image stacks. RESULTS: After 2 irrigations with 0.1% NVC-422, S. aureus biofilm biomass was reduced when compared to control sinuses (p = 0.0001), though this effect was variable in samples. NVC-422 0.5% solution irrigations reduced biofilm even more significantly and consistently over all samples (p < 0.0001). NVC-422 0.5% was also more effective than 0.1% NVC-422, vehicle control, and normal saline sinus irrigations in reducing biofilm biomass (p < 0.05 for all subgroups). No adverse events were observed in sheep after sinus irrigations with 0.1% and 0.5% NVC-422 solutions. CONCLUSION: NVC-422 is an effective topical agent against S. aureus biofilms, with dose-dependent efficacy in this animal model of biofilm-associated sinusitis.

Quantitative analysis of in vivo mucosal bacterial biofilms.

BACKGROUND: Quantitative assays of mucosal biofilms on ex vivo samples are challenging using the currently applied specialized microscopic techniques to identify them. The COMSTAT2 computer program has been applied to in vitro biofilm models for quantifying biofilm structures seen on confocal scanning laser microscopy (CSLM). The aim of this study was to quantify Staphylococcus aureus (S. aureus) biofilms seen via CSLM on ex situ samples of sinonasal mucosa, using the COMSTAT2 program. METHODS: S. aureus biofilms were grown in frontal sinuses of 4 merino sheep as per a previously standardized sheep sinusitis model for biofilms. Two sinonasal mucosal samples, 10 mm × 10 mm in size, from each of the 2 sinuses of the 4 sheep were analyzed for biofilm presence with Baclight stain and CSLM. Two random image stacks of mucosa with S. aureus biofilm were recorded from each sample, and analyzed using COMSTAT2 software that translates image stacks into a simplified 3-dimensional matrix of biofilm mass by eliminating surrounding host tissue. Three independent observers analyzed images using COMSTAT2 and 3 repeated rounds of analyses were done to calculate biofilm biomass. RESULTS: The COMSTAT2 application uses an observer-dependent threshold setting to translate CSLM biofilm images into a simplified 3-dimensional output for quantitative analysis. Intraclass correlation coefficient (ICC) between thresholds set by the 3 observers for each image stacks was 0.59 (p = 0.0003). Threshold values set at different points of time by a single observer also showed significant correlation as seen by ICC of 0.80 (p < 0.001). CONCLUSION: COMSTAT2 can be applied to quantify and study the complex 3-dimensional biofilm structures that are recorded via CSLM on mucosal tissue like the sinonasal mucosa.

Aspergillus fumigatus biofilm on primary human sinonasal epithelial culture.

BACKGROUND: Bacterial biofilms have been implicated in chronic rhinosinusitis (CRS). However, direct evidence in support of fungal biofilms in sinus disease is lacking in the literature. This study was designed to develop and characterize an in vitro Aspergillus fumigatus biofilm model on primary human sinonasal epithelial cell culture. METHODS: Sinonasal biopsy specimens harvested during endoscopic sinus surgery of six CRS patients and three pituitary tumor (control) patients were cultured in Dulbecco's modified Eagle media (DMEM; Invitrogen)/Hams F12 airway media to encourage epithelial cell proliferation. Epithelial cells separated by immunomagnetic beads were seeded in tissue culture-treated Y-shaped microslides. At confluence the primary cultures were inoculated with A. fumigatus spores. Fungus was allowed to germinate and form biofilms under two in vitro conditions: (1) static (no flow through of media) and (2) continuous flow coculture (continuous flow movement of media). At regular intervals cocultures were stained with FUN-1, concanavalin A-alexa fluor 488, and examined by confocal scanning laser microscopy. Comstat software was used to assess biomass and thickness. RESULTS: A. fumigatus formed three-dimensional biofilm structures with parallel-packed, cross-linked hyphae and channels/passages. Metabolically active hyphae showed orange-red fluorescing intravacuolar structures. Extracellular matrix (ECM) between/around the hyphae fluoresced intense green. A. fumigatus biofilms development occurred in five stages: (1) conidial attachment to epithelial cells, (2) hyphal proliferation, (3) ECM production, (4) hyphal parallel packing and cross-linking, and (5) channel/pores formation. Mature biofilms showed basal conidial, middle hyphal, and superficial ECM layers. Biofilms formed under flow conditions displayed more robust and faster growth kinetics when compared with that under static conditions, with a thick, stocky, wrinkly/undulating hyphal growth and extensive ECM production. The differences in biomass and average thickness of the cocultures under static and flow conditions were statistically significant after similar periods of incubation (p = 0.0002; p < 0.0001, respectively). CONCLUSION: To our knowledge, this is the first article of an in vitro model characterizing A. fumigatus biofilm formation using primary human sinonasal epithelium under different growth conditions.

Staphylococcus aureus biofilms: Nemesis of endoscopic sinus surgery.

OBJECTIVES/HYPOTHESIS: Chronic rhinosinusitis (CRS) patients with biofilms have persistent postoperative symptoms, ongoing mucosal inflammation, and recurrent infections. Recent evidence suggests that biofilms of differing species confer varying disease profiles in CRS patients. We aimed to prospectively investigate the effects of Staphylococcus aureus, Pseudomonas aeruginosa, Haemophilus influenzae, and fungal biofilms on outcomes following endoscopic sinus surgery (ESS). STUDY DESIGN: Prospective blinded study. METHODS: In this prospective blinded study, 39 patients undergoing ESS for CRS assessed their symptoms preoperatively using internationally accepted standardized symptom scoring systems and quality-of-life measures (10-point visual analog scale, Sino-Nasal Outcome Test-20, global severity of CRS). Their sinonasal mucosa was graded (Lund-Kennedy scale) and extent of radiologic disease on computed tomography scans scored (Lund-McKay scale). Random sinonasal tissue samples were assessed for different bacterial species forming biofilms by using fluorescent in-situ hybridization and confocal laser microscopy. For 12 months after surgery, CRS symptoms, quality of life, and objective evidence of persisting disease were assessed by using the preoperative tools. RESULTS: Different bacterial species combinations were found in 30 of 39 patients; 60% of these 30 biofilms were polymicrobial biofilms and 70% had S aureus biofilms. Preoperative nasendoscopy and radiologic disease severity were significantly worse in patients with multiple biofilms (P = .02 and P = .01, respectively), and they had worse postsurgery mucosal outcomes on endoscopy (P = .01) requiring significantly more postoperative visits (P = .04). Those with S aureus biofilms progressed poorly with their symptom scores and quality-of-life outcomes, with significant differences in nasendoscopy scores (P = .007). CONCLUSIONS: S. aureus biofilms play a dominant role in negatively affecting outcomes of ESS with persisting postoperative symptoms, ongoing mucosal inflammation, and infections.

A sheep model to investigate the role of fungal biofilms in sinusitis: fungal and bacterial synergy.

BACKGROUND: The role of fungi in the spectrum of chronic rhinosinusitis (CRS) is poorly understood. Fungal biofilms have recently been discovered in CRS patients. We have developed an animal model for the investigation of sinonasal fungal biofilms. The role of type I hypersensitivity and pathogenic bacteria is presented. METHODS: Thirty sheep were sensitized with fungal antigens-Aspergillus fumigatus and Alternaria alternata, or control. Endoscopic surgery was performed to expose both frontal sinus ostia-1 was occluded. Fungi with or without Staphylococcus aureus were inoculated into the sinus. Skin-prick tests assessed for fungal allergy. Fungal and S. aureus biofilms, histology, and culture rates were assessed. RESULTS: Forty-five percent of experimental sheep were sensitized to fungal antigen. Only 1 sinus inoculated with fungus developed minimal fungal biofilm. Eighty percent developed fungal biofilm when S. aureus was co-inoculated. The presence of hypersensitivity to fungus was not related to fungal biofilm development. CONCLUSION: Significant fungal biofilm only occurred when S. aureus was the co-inoculum. Hypersensitivity was not requisite. The relationship of S. aureus to fungal biofilms is of great clinical interest. Fungi may be opportunistic pathogens that simply require inflamed mucosa with weakened innate defenses; alternatively, a cross-kingdom synergy could be contributing to fungal proliferation.

Effect of head position and surgical dissection on sinus irrigant penetration in cadavers.

BACKGROUND: Effective treatment for recalcitrant rhinosinusitis requires unobstructed surgical marsupialization of sinus cavities and use of delivery systems that will topically penetrate the sinuses. AIMS: To determine the extent of sinus penetration achieved with nasal irrigation by varying the ostial size and head position. METHODS: Ten thawed fresh-frozen cadaver heads were dissected in a staged manner. After each stage of dissection, sinus squeeze-bottle irrigations were performed in three head positions, and endoscopes placed via external ports into the sinus cavities viewed the sinus ostia. An ordinal scale was developed to grade ostial penetration of irrigations. Three reviewers independently graded the outcomes. RESULTS: Irrigant entry into sinuses increased with ostial size (P < .001) and the greatest differential of improvement in sinus penetration is obtained at an ostial size of 4.7 mm. Stages 2 and 3 (larger sinus ostia) of maxillary and sphenoid dissections have statistically greater irrigant penetration relative to earlier stages. Frontal sinus irrigation is worse in vertex to ceiling head position. There does not appear to be any significant advantage to head position with maxillary and sphenoid sinuses. CONCLUSIONS: This study shows that the larger the sinus ostium, the better the penetration of irrigant into the sinus, with an ostium of at least 4.7 mm allowing maximal penetration in the maxillary and sphenoid sinuses. The same benefit was not noted in the frontal sinus. Head position was only relevant to the frontal sinus where less penetration was seen with the head neutral (vertex to ceiling) position when compared to forward angled positions.

The impact of biofilms on outcomes after endoscopic sinus surgery.

BACKGROUND: Although biofilms have been implicated in the pathogenesis of chronic rhinosinusitis (CRS), there is little evidence that their presence or absence has any effect on the outcomes of endoscopic sinus surgery (ESS). The aim of this study was to investigate the effect of biofilms on postsurgical outcomes after ESS. METHODS: A prospective, blinded study of 51 consecutive patients undergoing ESS for CRS was conducted. Preoperatively, patients assessed their symptoms using internationally accepted standardized symptom scoring systems and quality-of-life (QOL) measures, i.e., the 10-point Visual Analog Scale (VAS), Sino-Nasal-Outcome-Test 20, and global severity of CRS. Their sinonasal mucosa was graded using the Lund-Kennedy scale and the extent of radiological disease on computed tomography scans was scored using the Lund-McKay scale. Random sinonasal tissue samples were assessed for biofilm presence using confocal laser microscopy. At each postoperative visit, patients reassessed their sinus symptoms and completed QOL measures. Postsurgical state of their sinonasal mucosa was graded endoscopically. RESULTS: Bacterial biofilms were found in 36 of 51 (71%) CRS patients. Patients with biofilms presented with significantly worse preoperative radiology and nasendoscopy scores (p = 0.003 and 0.01, respectively). After a median follow-up period of 16 months postsurgery, biofilm-positive patients had statistically worse sinus symptoms (VAS, p = 0.002) and worse nasendoscopy scores (p = 0.026). They also required extra postoperative visits and multiple antibiotic treatments deviating from the standard postoperative care required by biofilm-negative patients. CONCLUSION: This study has shown that patients with biofilms have more severe disease preoperatively and persistence of postoperative symptoms, ongoing mucosal inflammation, and infections. This study strengthens the evidence for the role that biofilms may play in recalcitrant CRS.

Targeted imaging modality selection for bacterial biofilms in chronic rhinosinusitis.

OBJECTIVES/HYPOTHESIS: Biofilms are increasingly recognized as having an etiological role in chronic rhinosinusitis (CRS). Research into biofilms in CRS currently relies on microscopic imaging techniques, none of which are universally accepted. This study compares LIVE/DEAD BacLight (Invitrogen Corp., Carlsbad, CA) staining and fluorescence in situ hybridization (FISH), both utilizing the confocal scanning laser microscope (CSLM) for biofilm determination and characterization in CRS patients. STUDY DESIGN: Prospective study. METHODS: Twenty CRS patients undergoing endoscopic sinus surgery were recruited for the study. Sinus mucosal tissue harvested at the time of surgery underwent both the BacLight/CSLM and FISH/CSLM protocols for biofilm determination and characterization. RESULTS: Combining the results of both protocols, 18/20 (90%) patients had bacterial biofilms demonstrable on at least one modality. The high biofilm detection rate combining the two techniques suggests the prevalence of biofilms in CRS may be greater than previously reported. The protocols had equivalent results in 15/20 patients. Using the differences observed in the remaining five patients, we can highlight the most appropriate use for each technique. CONCLUSIONS: BacLight/CSLM and FISH/CSLM are complementary techniques for biofilm determination and characterization. Both protocols are suited to different research areas and the selection of technique used should be based on the specific objectives of the research protocol. In this way we can utilize the advantages of each technique to facilitate effective research.

A prospective controlled trial of pulsed nasal nebulizer in maximally dissected cadavers.

BACKGROUND: Nasal douching is common practice in treatment of chronic sinusitis and after endoscopic sinus surgery. Current nasal delivery techniques show inconsistent sinus penetration. The aim of this study was to compare sinonasal penetration of nasal douching to an optimized nasal nebulizer in an operated cadaver model. METHODS: Fourteen preserved cadavers were used receiving complete sphenoethmoidectomies with a Draf III, wide maxillary antrostomy, or medial maxillectomy. Seven control cadavers received nasal douching with one standardized squeeze bilaterally of a 200-mL nasal irrigation bottle and seven intervention cadavers were nebulized with 3 minutes of the PARI sinus device bilaterally. Douching solutions were stained with methylene blue. Independent observers documented sinonasal anatomy, staining intensity, and percentage area covered by dye using standardized grading protocols. RESULTS: Combined data showed a significant increase in intensity of stain (2.06 versus 0.26, p < 0.001), percentage of stain (49.96% versus 4.19%, p < 0.001), and circumference stained (76.59% versus 12.7%, p < 0.001) with the plastic nasal irrigation squeeze bottle versus PARI device. Analysis of individual sinuses consistently showed significant increases in indices of nasal douching relative to nebulization. The PARI sinus nebulizer was noted to reach the ethmoids regularly (92% incidence), whereas the other sinuses were not reached as regularly with incidences noted at frontal (43%), maxillary (46%), and sphenoid (54%). This compares to 96% of all sinuses being stained by the squeeze bottle. CONCLUSION: In all measured indices, the nasal douching method with the squeeze bottle was superior to the PARI sinus nebulizer in highly dissected sinonasal cadaver models.

The incidence of complications using new landmarks and a modified technique of canine fossa puncture.

BACKGROUND: Canine fossa puncture (CFP) is a technique that improves access to the maxillary sinus and may be required to ensure complete disease removal from this sinus. Traditional approaches through the canine fossa often have resulted in injury to branches of the infraorbital nerve. The aim of this study was to determine the frequency, severity, and duration of complications using recently described. landmarks for determining the optimal site for anatomically directed CFP (aCFP) and a new endoscopic retractor and drill guide that enable endoscopically guided canine fossa trephination (eCFT). These complication rates have been compared with those that we have described previously using a standard technique of CFP. METHODS: A total of 63 patients were included with 36 bilateral procedures giving a total number of 99 procedures performed. Of these, 32 procedures were performed using anatomic landmarks (aCFP) and 67 were performed with additional endoscopic guidance (eCFT). Patients were assessed at a mean time of 12.6 months (range, 3-26 months) after surgery by telephonic survey and their complications were assessed and graded for severity on a 0- to 10-point scale. RESULTS: The combined frequency of adverse events after aCFP and eCFT were 45% compared with the previously reported 76% with the traditional technique (p = 0.001). The number of patients complaining of persisting adverse effects was reduced from 29% after CFP to 5% after aCFP and eCFT (p < 0.001). The 67 eCFT technique had a significantly lower frequency of adverse events (40%) than the aCFP technique (53%; p < 0.05). CONCLUSION: The recently described landmarks to site the CFP result in statistically fewer complications. This complication rate is further reduced if CFT is performed under direct endoscopic vision.

Sinonasal leiomyoma: report of 2 cases.

Leiomyomas are benign smooth-muscle tumors that are common in the alimentary tract, uterus, skin, and subcutaneous tissue. They are very uncommon in the upper respiratory tract and rare in the nasal cavity and paranasal sinuses. To the best of our knowledge, only 23 such cases have heretofore been published in the literature. We report 2 new cases of sinonasal leiomyoma that originated at different sites in the nasal cavity. We also discuss the various investigative and therapeutic modalities available.

Balloon cell nevus of the pharynx.

BACKGROUND: Mucosal melanotic lesions are rare, and the still rarer balloon cell variant has not been reported in the upper aerodigestive tract mucosa. We report a case of balloon cell nevus of the pharynx. METHODS: A 35-year-old woman was seen with complaints of a black color in her mouth. Physical examination revealed a diffusely pigmented posterior pharyngeal wall. The pigmentation extended superiorly to the posterior edge of the palate, and laterally, it stopped short of the posterior tonsillar pillars. The overlying mucosa was smooth, with no swelling. Flexible endoscopy showed that the lesion extended to the cricopharynx. Findings on histopathologic examination were consistent with balloon cell nevus of the pharynx. Complete excision was not possible, because the lesion was very diffuse. RESULTS: After 2 years of conservative management and regular follow-up examinations, no change in the symptoms and no increase in the lesion have been seen. CONCLUSION: Melanotic lesions in the upper aerodigestive tract mucosa are rare. This case is reported for its rarity, unusual presentation, and characteristic histopathologic features.

An amazing gunshot injury of the head and neck.

As the use of firearms has become more prevalent in society, both the number of homicidal & suicidal victims has increased Injuries from gunshot wounds, of the face and neck vary in extent and significance, forming a spectrum from trivial to life-endangering lesions. The face and the neck have many vital structures confined to a small area of the body, and hence, it has a greter potential of leading to a fatality in the event of trauma. We report a case of a civilian homicidal firearm injmy sustained in the head & neck region, with the bullet having travelled through the head & neck region without causing any mortality and minimal morbidity to the victim.