Middle meatal nasal recesses of the maxillary sinuses and dangerously modified nasal anatomy.

Pneumatisation of the maxillary sinus (MS) is variable. The archived cone-beam computed tomography file of a 54-year-old female was retrospectively evaluated anatomically. Nasal or retrobullar recesses of the MSs (NRMS) were found. The MSs were bicameral. NRMSs extended from the postero-lateral chambers of the MSs into the lateral nasal walls. The right NRMS was reached superior to the middle turbinate and the ethmoidal bulla was applied on its anterior side. The left NRMS had two medial pouch-like ends, one beneath the ethmoidal bulla and the other on the anterior side of the basal lamella of the middle turbinate. Additional anatomical findings were the uncinate bulla, infraorbital recesses of the MS, maxillary recess of the sphenoidal sinus, and atypical posterior insertions of the superior nasal turbinates, maxillo-ethmoido-sphenoidal and ethmoido-sphenoidal. The NRMS is a novel finding and could lead to erroneous endoscopic corridors if not documented before the interventions.

Non-intestinal-type adenocarcinoma of the nasal cavity and paranasal sinuses: an analysis of clinical characteristics and prognosis.

BACKGROUND: Non­intestinal adenocarcinoma of the nasal cavity and paranasal sinuses (non­ITAC) is a heterogeneous tumour that has rarely been reported in previous studies. We compared and analysed the symptoms, radiographic and pathological features, treatment methods, and prognosis of patients with low-grade (G1) and high-grade (G3) tumours. METHODS: This was a retrospective study included 22 patients with pathologically confirmed non-ITAC of the nasal cavity and paranasal sinuses who were treated between January 2008 and December 2021 at a single centre. Of these, 11 patients had G1 tumours, and 11 patients had G3 tumours. Clinicopathological features, treatment methods, and survival outcomes were analysed. RESULTS: The median follow-up period was 48.5 months. Nasal congestion was the most common initial symptom, and the nasal cavity was the most frequently involved site. For G1 tumours, the main treatment was simple surgery, 1 and 3­year overall survival (OS) rates were 100 and 88.9%, while the 1 and 3­year local control (LC) rates were 100 and 100%, respectively. For G3 tumours, the main treatments were surgery combined with radiotherapy and/or chemotherapy,1 and 3­year OS rates were 72.7 and 72.7%, while the 1 and 3­year LC rates were 100 and 90.91%, respectively. G3 tumours was associated with significantly shorter overall survival than G1 tumours (P = 0.035). Patients with stage III-IV showed shorter overall survival compared to stage I-II patients (P = 0.035). CONCLUSIONS: Non-ITAC of the nasal cavity and paranasal sinuses may frequently occur in the nasal cavity. The main treatment modality is surgery, supplemented by radiotherapy and chemotherapy. Pathological grade and tumour stage were poor prognostic factors for the disease.

Low-grade myofibrosarcoma of the maxillary sinus: Two case reports.

BACKGROUND: Low-grade myofibroblastic sarcoma (LGMS) is an extremely rare tumor characterized by the malignant proliferation of myofibroblasts. LGMS most commonly develops in adults, predominantly in males, in the head and neck region, oral cavity, especially on the tongue, mandible, and larynx. This article presents 2 cases of LGMS localized to the maxillary sinus and provides an overview of the available literature. CASE SUMMARY: Two patients with LGMS located in the maxillary sinus underwent surgery at the Department of Head and Neck Surgery. Case 1: A 46-year-old patient was admitted to the clinic with suspected LGMS recurrence in the right maxillary sinus (rT4aN0M0), with symptoms of pain in the suborbital area, watering of the right eye, thick discharge from the right nostril, and augmented facial asymmetry. After open biopsy-confirmed LGMS, the patient underwent expanded maxillectomy of the right side with immediate palate reconstruction using a microvascular skin flap harvested surgically from the middle arm. The patient qualified for adjuvant radiotherapy for the postoperative bed, with an additional margin. Currently, the patient is under 1.5 years of observation with no evidence of disease. Case 2: A 45-year-old man was admitted to our clinic with facial asymmetry, strabismus, exophthalmos, and visual impairment in the right eye. Six months earlier, the patient had undergone partial jaw resection at another hospital for fibromatosis. A contrast-enhanced computed tomography scan revealed a tumor mass in the postoperative log after an earlier procedure. An open biopsy confirmed low-grade fibrosarcoma (rT4aN0M0). The patient qualified for an extended total right maxillectomy with orbital excision and right hemimandibulectomy with immediate microvascular reconstruction using an anterolateral thigh flap. The patient subsequently underwent adjuvant radiotherapy to the postoperative area. After 9 months, recurrence occurred in the right mandibular arch below the irradiated area. The lesion infiltrated the base of the skull, which warranted the withdrawal of radiotherapy and salvage surgery. The patient qualified for palliative chemotherapy with a regimen of doxorubicin + dacarbazine + cyclophosphamide and palliative radiotherapy for bone metastases. The patient died 26 months after surgical treatment. The cases have been assessed and compared with cases in the literature. CONCLUSION: No specific diagnostic criteria or treatment strategies have been developed for LGMS. The treatment used for LGMS is the same as that used for sinonasal cancer radical tumor excision; adjuvant radiotherapy or chemoradiotherapy should also be considered. They have low malignant potential but are highly invasive, tend to recur, and metastasize to distant sites. Patients should undergo regular follow-up examinations to detect recurrence or metastasis at an early stage. Patients should be treated and observed at the highest referral centers.

Sexual dimorphism of maxillary sinuses in adult population using cone-beam computed tomography. A pilot study.

Objective: This study aims to evaluate the sexual dimorphism of maxillary sinuses (MS) using cone-beam computed tomography (CBCT). Method: A total of 80 CBCT scans were taken from Peruvian patients aged between 20 and 70 years-old. The dimensions (length, width, and height) of the MS were measured and evaluated. The data were analyzed using the Mann-Whitney U test with a significance level of p < 0.05. Results: The left MS was wider than the right MS. Meanwhile, the right MS was longer than the left MS. In addition, the height of the right and left MS was significantly different in males and females, with p-value of 0.003 and 0.044 respectively. Bigger dimension of height of the MS was found in patients aged between 30 and 39 as well as patients aged between 40 and 49, whereas smaller dimension of height of the MS was found in patients aged between 60 and 70. Furthermore, the height of the right MS was significantly different in dentate and edentulous patients, with p-value of 0.033 and 0.043 respectively. The height of the right MS was predicted at 65 % in males and 70 % in females (p = 0.002). Conclusion: The morphometry of the maxillary sinuses can be used for predicting sexual dimorphism.

Early diagnosis and aggressive surgical resection matters to cure rhinocerebral mucormycosis: Six case reports.

Rhino-cerebral mucormycosis (RM) is a rare and opportunistic fungal infection observed in immune-compromised patients and metabolic imbalances such as Diabetes Mellitus. RM rapidly infiltrates blood vessels, leading to vascular thrombosis, subsequent tissue necrosis, and high mortality rates (23.6-60%). Due to its fast advancement, RM is a life-threatening condition requiring accurate clinical decisions by the medical and surgical teams. Based on the report of six cases, we emphasize the need for an early diagnosis and starting antifungal pharmacological therapy at the slightest suspicion of RM. Moreover, the restitution of metabolic balance and aggressive surgical debridement are vital steps to control RM, reducing the possibility of fatal outcomes.

Emergence characteristics comparing endotracheal tube to reinforced laryngeal mask airway during endoscopic sinus surgery - A randomised controlled study.

Background and Aims: During endoscopic sinus surgery, anaesthetic conditions significantly impact the intraoperative surgical field and bleeding during emergence. While the endotracheal tube (ETT) has been traditionally used in sinus surgery, a reinforced laryngeal mask airway (RLMA) that produces less upper airway stimulation may result in smoother emergence. Methods: A randomised controlled trial of 72 patients undergoing elective sinus surgery was conducted, with the allocation of airway technique to either ETT with a throat pack or RLMA. The primary outcome measure was emergence time, measured by time to opening eyes on commands at the cessation of anaesthesia, and the secondary outcomes were time to removal of airway device, remifentanil use, procedure times, mean arterial pressure (MAP) and the RLMA grade of blood contamination. The continuous variables were analysed using Student's t-tests and discrete variables, count tables were analysed using Fisher's exact tests. Results: There was no significant difference in the emergence time between the ETT and RLMA groups (P = 0.83). Remifentanil use was significantly higher in the ETT group than in the RLMA group (P = 0.022). The ETT group showed a significantly increased total anaesthetic time (P = 0.01). MAP was not significant during preinduction, maintenance or post-RMLA removal. The highest grade of contamination was grade 2 in RLMA. RLMA had lower rates of postoperative adverse events. Conclusions: RLMA comparable to ETT in terms of emergence time. The RMLA group had lower remifentanil use, anaesthesia duration and fewer postoperative adverse events such as cough and throat pain.

Unruptured giant lateral thoracic meningocele: extremely rare cause of cerebrospinal fluid (CSF) hypotension in neurofibromatosis type 1.

Neurofibromatosis type 1 (NF1) is a multisystem neurocutaneous disorder. Scoliosis and dural ectasia are features of the associated mesodermal dysplasia. Lateral thoracic meningoceles can develop in NF1 and progressively enlarge due to cerebrospinal fluid (CSF) pulsations. Large meningoceles can cause compressive symptoms in the thorax. We are reporting a case of a NF1 presenting with acute onset respiratory distress, who also had chronic orthostatic headaches. CT chest showed unruptured enlarging bilateral lateral thoracic meningoceles causing lung compression. MRI of the brain and spine showed features of CSF hypotension, explaining the headaches. CSF hypotension with unruptured meningoceles is extremely rare. Management of the condition is challenging since surgical removal is prone to complications due to underlying mesodermal abnormalities. Cystoperitoneal shunting to relieve lung compression may worsen CSF hypotension. A shunt with a programmable valve allowed controlled drainage and successfully relieved lung compression without worsening of orthostatic headaches in our case.

Presence of herpesviruses, parvoviruses, and polyomaviruses in sinonasal lymphoma.

PURPOSE: Sinonasal lymphoma (SL) is a rare lymphatic neoplasm of the nasal cavities, paranasal sinuses and nasopharynx. Whereas some risk factors for SL subtypes have been identified, their aetiology is unknown. Along with other predisposing factors, the viral association of lymphomas, such as Epstein-Barr virus (EBV) and Burkitt and Hodgkin lymphomas, is well-established. Modern molecular biology techniques have enabled the discovery of novel human viruses, exemplified by the protoparvovirus cutavirus (CuV), associated with cutaneous T-cell lymphoma. These findings, and the anatomical location of the sinonasal tract with its rich microbiome and infectious agents, justify in-depth studies among SL. METHODS: We analysed the presence of 20 viruses of Orthoherpesviridae, Parvoviridae, and Polyomaviridae by qPCR in 24 SL tumours. We performed RNAscope in situ hybridisation (RISH) to localize the viruses. Parvovirus-specific IgG was analysed by enzyme immunoassay and targeted next-generation sequencing (NGS) was applied to detect CuV in plasma. RESULTS: We detected viral DNA in 15/24 (63%) tumours; nine of EBV, six of human herpesvirus (HHV) -7, four each of HHV-6B and parvovirus B19, two of cytomegalovirus, and one each of CuV and Merkel-cell polyomavirus. We found tumours with up to four viruses per tumour, and localized CuV and EBV DNAs by RISH. Two of the ten plasma samples exhibited CuV IgG, and one plasma sample demonstrated CuV viremia by NGS. CONCLUSION: Viruses were frequent findings in SL. The EBV detection rate was high in diffuse large B-cell lymphoma, and co-detections with other viruses were prevalent.

Feasibility of Optical Biopsy During Endoscopic Sinus Surgery With Confocal Laser Endomicroscopy: A Pilot Study.

OBJECTIVE: Confocal laser endomicroscopy (CLE) is an optical imaging technique that allows in vivo, real-time, microscope-like assessment of superficial lesions. Although there is substantial data on CLE use in the upper GI tract, there is limited information regarding its application in the nasal cavity and paranasal sinuses. This study aims to assess the feasibility and diagnostic metrics of CLE in the nasal cavity and paranasal sinuses regarding differentiation between healthy/benign and malignant tissue. These structures show, however, a wider variety of frequent and concomitant benign and malignant pathologies, which could pose an increased challenge for optical biopsy by CLE. METHODS: We performed CLE on a case series of six patients with various findings in the nose (three chronic rhinosinusitis, adenocarcinoma, meningoenzephalozele, esthesionneuroblastoma). Forty-two sequences (3792 images) from various structures in the nasal cavity and/or paranasal sinuses were acquired. Biopsies were taken at corresponding locations and analyzed in hematoxylin and eosin staining as a standard of reference. Three independent examiners blinded to the histopathology assessed the sequences. RESULTS: Healthy and inflamed mucosa could be distinguished from malignant lesions with an accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of 84.1%, 85.4%, 83.1%, 72.5%, and 92.1%, respectively, with a substantial agreement between raters (Fleiss κ = 0.62). CONCLUSION: This technique shows, despite its limitations, potential as an adjunctive imaging technique during sinus surgery; however, the creation of a scoring system based on reproducible and defined characteristics in a larger more diverse population should be the focus of further research to improve its diagnostic value and clinical utility. LEVEL OF EVIDENCE: NA Laryngoscope, 2024.

Location of infraorbital and accessory infraorbital foramina in Iranian population: a retrospective radiological study with crucial clinical implications.

PURPOS: The location of infraorbital foramen (IOF) and the prevalence of accessory IOF vary among different populations. It may lead to infraorbital nerve (ION) blockage during surgery. This study aimed to assess the IOF location and AIOF frequency in Iranian people. METHOD: In this retrospective cross-sectional study, 500 paranasal sinus computed tomography scans of adults were examined using the INFINITT PACS system. RESULT: The distance from IOF to infraorbital margin (IOM), mid-pupillary line (MPL), midsagittal line (MSL), canine eminence (CE), and skin thickness (ST) was 8.97 ± 1.79, 5.73 ± 1.84, 24.86 ± 2.23, 20.39 ± 3.47, and 10.90 ± 2.59 mm, respectively. The vertical and transverse diameters of the foramen were 3.03 ± 0.65 and 3.71 ± 0.76 mm, respectively. In addition, the shape of 63.5% of the foramina was oval. The prevalence of AIOF was 9%, and its most common location was superomedial to IOF. CONCLUSION: We believe that in this study, landmarks like IOM, MPL, MSL, CE and ST could help the clinicians localize IOF and improve the ION anesthesia success rate. Furthermore, the occurrence of AIOF should be considered by physicians to reduce the chance of injuries to the infraorbital neurovascular complex.

Efficacy and safety of dupilumab in the treatment of CRSwNP in the real-life setting: a review of the literature.

INTRODUCTION: The recent approval of Dupilumab has profoundly revolutionized the management of patients affected by severe and recalcitrant Chronic Rhinosinusitis with Nasal Polyps (CRSwNP). However, a review that summarizes the results of real-life studies and compares them to phase 3 studies SINUS-24 and 52 is still lacking. MATERIALS AND METHODS: A search of all real-life studies published from 2019 to 2023 was performed. Patients characteristics at baseline and 6 and 12 months after starting Dupilumab were extracted and compared to those from phase 3 trials: age, sex, smoking habits, comorbid asthma and aspirin-exacerbated respiratory disease (AERD), previous endoscopic sinus surgery (ESS), hematic eosinophils and total IgE, NasalAQ2 Polyps Score (NPS), smell, SNOT-22, adverse events (AEs), and response to treatment. RESULTS: 15 papers were included with an overall number of 1658 patients. A higher rate of comorbidities and previous ESS was found in patients from real-life studies. In addition, they had worse smell and SNOT-22 at baseline compared to patients from SINUS-24 and 52. Comorbid and post-ESS patients tended to have a faster NPS and SNOT-22 improvement, although the absolute values were not clinically relevant. A more extensive surgery and a number of ESS ≥ 2 were related to worse olfactory outcomes, probably due to iatrogenic damage. No correlation was found between hematic eosinophils and outcomes. AEs were reported by 12.4% of patients and 2.2% had to discontinue dupilumab. Weight gain was an emergent AE (0.8%), probably related to the restored sense of smell and taste. Non-responders were 3.5% and they were switched to systemic steroid, ESS, or another biologic. CONCLUSION: Despite some differences in prescription criteria between countries, dupilumab was demonstrated to be effective even in the real-life scenario. However, emerging AEs and possible unknown long-term AEs of a likely lifelong therapy should be considered.

Granulomatous Inflammation of the Skull Base: A Rare Case of Mycobacterium tuberculosis in the United States.

The differential for an ill-defined, bone-destructive, granulomatous lesion of the skull base includes malignancy, as well as autoimmune and infectious processes. Suspicion for tuberculosis of the skull base in high-risk patients is particularly necessary given the difficulty to culture on standard cultures, need for specific and prolonged antibiotic therapy, and dire morbidity if not diagnosed and treated in a timely manner. Repeat biopsies and cultures were necessary to diagnose this case of Mycobacterium tuberculosis of the skull base after initial biopsy was non-diagnostic. Laryngoscope, 2024.

Three-Dimensional Volumetric Investigation of Onodi Cells: A Multi-Slice Computed Tomography Study.

Introduction Onodi cells (OCs) are posterior ethmoid cells that are located above the sphenoid sinus, close to or even surrounding the carotid artery and optic nerve. Objective To investigate and evaluate the volumetric variation of OCs through multi-slice computed tomography (MSCT) scans. Methods We performed a retrospective review of MSCT scans of 79 subjects, 40 male and 39 female patients, Whose age ranged from 18 to 83 (mean: 39.6) years. The volumes of the OCs on the right and left sides were measured using the ITK-SNAP software (open-source) with semiautomatic segmentation. The possible relationships involving age, gender, contact with the optic nerve, extension of the pneumatization of the posterior ethmoid cells into the clinoid processes, mucous thickening in the anterior and posterior ethmoid cells, and obliteration of the sphenoethmoidal complex were analyzed with the Pearson correlation and Chi-squared tests according to the type of data compared and logistic regression models ( p < 0.05). Results We observed that an increase of one unit in the volume of OCs also increases the chance of extension of pneumatization into the clinoid processes by 0.15% ( p = 0.001). No significant correlations were identified regarding age, gender, and volume of the OCs. Conclusion The volume of the OCs has effects on the extension of pneumatization into the clinoid processes.

Endoscopic surgical field clarity index: An artificial intelligence-based measure of transnasal endoscopic surgical field quality.

KEY POINTS: Clear visualization during transnasal endoscopic surgery (TNES) is crucial for safe, efficient surgery. The endoscopic surgical field clarity index (ESFCI) is an artificial intelligence-enabled measure of surgical field quality. The ESFCI allows researchers to evaluate interventions to improve visualization during TNES.

Invasive Fungal Sinusitis in an Immunocompetent Patient After Sinus Surgery for Chronic Rhinosinusitis with Nasal Polyps and a Mycetoma.

Acute invasive fungal sinusitis (AIFS) classically presents as an aggressive fungal infection that can spread beyond its origin in the sinuses in immunocompromised patients. Although there have been reports of AIFS in immunocompetent, non-diabetic patients, it is extremely rare and the true mechanism behind it is unknown. A thirty-eight year old immunocompetent, non-diabetic woman underwent bilateral ESS for chronic rhinosinusitis with nasal polyps at a tertiary care center and post-operatively developed AIFS. Patient underwent uncomplicated ESS, was packed with foam containing triamcinolone and discharged on steroid rinses and a prednisone taper. Surgical pathology demonstrated left-sided colonization with non-invasive fungal elements consistent with a mycetoma. She presented on post-operative Day 11 with headache and left-sided retro-orbital pain. A culture of her left nasal cavity grew Rhizopus spp and MRI demonstrated evidence of invasive fungal infection of left sphenoid mucosa as well as inflammatory changes in the left orbit centered at the orbital apex. She was started on amphotericin and underwent a left-sided debridement with biopsies which demonstrated angioinvasive fungal disease. Her vision in her left eye worsened to 20/800 and she was treated with transcutaneous retrobulbar injection of amphotericin B. After stable interval imaging she was discharged on a long-term course of antifungals. Extensive immunologic work-up was unremarkable. We describe a case of an immunocompetent patient who developed AIFS after sinus surgery for CRS and a mycetoma likely as a result of local immune suppression and post-surgical trauma. Laryngoscope, 2024.

Correlation between Cross-Sectional Anatomy and Computed Tomography of the Normal Six-Banded Armadillo (Euphractus sexcintus) Nasal Cavity and Paranasal Sinuses.

This research aimed to study the rostral part of the head of the six-banded armadillo, applying advanced imaging techniques such as CT. Furthermore, by combining the images obtained through this technique with anatomical cross-sections, an adequate description of the structures that constitute the rostral part of the head of this species is presented. This anatomical information could provide a valuable diagnostic tool for the clinical evaluation of different disorders in the six-banded armadillo's nasal cavity and paranasal sinuses.

Chondrosarcoma of the Nasal Cavity and Paranasal Sinuses: A Rare Entity.

Background: Chondrosarcomas are slow-growing malignant tumors that originate in cartilaginous structures. They typically manifest in the head and neck region, with a preference for the maxillofacial skeleton, particularly the mandible and maxilla. However, chondrosarcoma of the sinonasal tract is exceptionally rare, and only few cases have been reported. Case Presentation: This report details the case of a 43-year-old woman who incidentally discovered chondrosarcoma in the maxillary and ethmoid sinuses with nasal extension. Subsequently, the patient underwent surgery via a paralatero-nasal approach with adjuvant radiotherapy. The aim of this study was to describe the clinical findings, management, and outcome of sinonasal tract chondrosarcoma. Conclusions: The primary treatment for chondrosarcomas remains surgery, with a transnasal endoscopic approach offering a viable option for complete resection in select cases.

Giant frontal sinus mucocele mimicked a primary brain tumor: A case report.

INTRODUCTION: Frontal sinus mucoceles commonly manifest with orbital complications. Intracranial complications, though rare, are significant in the differential diagnosis. Tumefactive and giant mucoceles can resemble intracranial tumors. CASE PRESENTATION: We present the case of a 24-year-old male patient who initially presented to our institution after experiencing a single generalized tonic-clonic seizure. Initial imaging revealed large masses in both frontal lobes. Surgical intervention revealed mucoceles originating from the frontal and paranasal sinuses. DISCUSSION: Mucoceles are often misdiagnosed due to the wide variety of symptoms they can present. In particular, the tumefactive type of mucoceles can present brain tumors both clinically and radiologically. CONCLUSION: Mucoceles can manifest as tumefactive lesions, mimicking intracranial masses, and may present as perplexing neurological conditions.