A stepwise approach to open surgery for the frontal sinus.

BACKGROUND: Despite advances in endoscopic techniques, there are still instances when the frontal sinus must be approached externally. Given its variable anatomy, the frontal sinus continues to present a challenge to the surgeon. Our rule of thumb capitalises on the consistent embryological development of the frontal sinus, aiding safe external access. METHODS AND RESULTS: The presented stepwise approach includes trephination, fenestration, an osteoplastic flap and obliteration. The obliteration procedure has produced good results in managing those patients with disabling symptoms despite multiple endoscopic procedures.

Nose and paranasal sinus tumours: United Kingdom National Multidisciplinary Guidelines.

This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. With only limited high-level evidence for management of nasal and paranasal sinus cancers owing to low incidence and diverse histology, this paper provides recommendations on the work up and management based on the existing evidence base. Recommendations • Sinonasal tumours are best treated de novo and unusual polyps should be imaged and biopsied prior to definitive surgery. (G) • Treatment of sinonasal malignancy should be carefully planned and discussed at a specialist skull base multidisciplinary team meeting with all relevant expertise. (G) • Complete surgical resection is the mainstay of treatment for inverted papilloma and juvenile angiofibroma. (R) • Essential equipment is necessary and must be available prior to commencing endonasal resection of skull base malignancy. (G) • Endoscopic skull base surgery may be facilitated by two surgeons working simultaneously, utilising both sides of the nose. (G) • To ensure the optimum oncological results, the primary tumour must be completely removed and margins checked by frozen section if necessary. (G) • The most common management approach is surgery followed by post-operative radiotherapy, ideally within six weeks. (R) • Radiation is given first if a response to radiation may lead to organ preservation. (G) • Radiotherapy should be delivered within an accredited department using megavoltage photons from a linear accelerator (typical energies 4-6 MV) as an unbroken course. (R).

The predictive value of structured ultrasonographic staging for thyroid nodules.

BACKGROUND: 'R staging' is a new ultrasonographic scoring system developed and used by our specialist head and neck radiologist for reporting sonographic risk of malignancy to those at our thyroid multidisciplinary team meeting. This study aimed to: classify the R staging system, examine its relationship with the eventual histopathological diagnosis and define its clinical utility. METHODS: The pre-operative ultrasound scans of 78 patients were assigned an R status by our specialist head and neck radiologist. The final histopathology report for each thyroid nodule was used as the 'gold standard' for analysis. RESULTS: When thyroid nodules were classified as low risk (R stages 1-3) or high risk (R stages 4-5) for malignancy, the sensitivity of R staging was 74.2 per cent and specificity was 80.9 per cent. An R5 status was 100 per cent predictive of malignancy. CONCLUSION: Our results compare favourably with other suggested ultrasonographic staging systems for thyroid nodules.

Endonasal, transmaxillary, transpterygoid approach to the foramen ovale: radio-anatomical study of surgical feasibility.

OBJECTIVE: This study aimed to examine the feasibility of an endonasal, transmaxillary, transpterygoid approach to the foramen ovale by examining key anatomical, radiological and surgical landmarks. METHOD: Measurements were taken from 183 patients' computed tomography scans using BrainLAB iPlan 1.1 Cranial software. Endoscopic dissection was then carried out on a cadaver to assess surgical viability. RESULTS: We found that the distances from the posterior maxillary wall to the foramen ovale and from the anterior nasal spine to the foramen ovale were statistically significantly larger in men than women. The distance from the base of the lateral pterygoid plate to the foramen ovale, and the angle between the foramen ovale, the anterior nasal spine and the sphenoid rostrum, were constant between the sexes. The importance of the lateral pterygoid plate in locating the foramen ovale was demonstrated. CONCLUSION: With the increasing popularity of image guidance and assisted navigation in endoscopic surgery, these findings increase anatomico-radiological understanding of the surgical approach investigated.

Image guidance in rhinology and anterior skull base surgery: five-year single institution experience.

OBJECTIVES: We examined our experience of image guidance surgery in rhinology, and compared image guidance surgery cases with non-image guidance cases. We also audited our practice against the American Academy of Otolaryngology-Head and Neck Surgery image guidance surgery guidelines. METHOD: The study employed a single institution retrospective approach comprising 174 image guidance surgery patients (106 males and 68 females) and 134 non-image guidance surgery patients (75 males and 59 females). RESULTS: In the image guidance surgery group, tumour operations represented 45 per cent of cases (55 per cent were non-neoplastic). Basic, intermediate and advanced (structured classification) procedures represented 19 per cent, 24 per cent and 61 per cent, respectively. Five minor complications were recorded. In non-image guidance surgery, tumour operations represented 8 per cent of cases (92 per cent were non-neoplastic). Basic, intermediate and advanced procedures represented 73 per cent, 12 per cent and 15 per cent, respectively. One minor complication was observed. CONCLUSION: We report the largest series of image-guided ENT surgical procedures in the UK. In the cases we examined, image guidance surgery was predominantly used in advanced procedures and tumour surgery.

Reversible nasal airway obstruction: does change in nasal peak inspiratory flow following decongestion predict response to topical steroids in chronic rhinosinusitis patients?

BACKGROUND: Predicting which chronic rhinosinusitis patients have nasal obstruction due to reversible mucosal inflammation could prevent unnecessary surgery. AIM: To investigate whether the change in nasal peak inspiratory flow following maximal decongestion (i.e. mucosal reversibility) at first visit predicts the response to topical steroids in chronic rhinosinusitis patients, as measured by the 22-item Sinonasal Outcome Test. METHODS: Prospective study of 128 consecutive new adult patients presenting with nasal obstruction due to chronic rhinosinusitis (January 2008 to July 2010). The 22-item Sinonasal Outcome Test questionnaire was administered and the nasal peak inspiratory flow assessed. Following maximal nasal decongestion, the nasal peak inspiratory flow was again tested and the difference calculated. Topical steroids were administered for at least six weeks. The 22-item Sinonasal Outcome Test was then repeated and the difference calculated. RESULTS: Data were analysed using means and correlation studies (Spearman's rank correlation). There was no correlation between the pre- versus post-decongestion nasal peak inspiratory flow difference and the pre- versus post-steroid 22-item Sinonasal Outcome Test difference, in chronic rhinosinusitis patients with or without nasal polyps. CONCLUSION: The difference between pre- and post-decongestion nasal peak inspiratory flow does not predict chronic rhinosinusitis patients' response to topical steroids.

The frontal osteoplastic flap: does it still have a place in rhinological surgery?

OBJECTIVE: To review outcomes and complications in a series of adults undergoing a frontal osteoplastic flap procedure without obliteration, for endoscopically inaccessible sinus disease. MATERIAL AND METHOD: Retrospective case note review of patients treated at Glasgow Royal Infirmary between January 2004 and October 2008. RESULTS: Ten patients were identified (age range 19-81 years, mean age 46.3 years). No major intra- or post-operative complications occurred. There were three minor complications: superficial discharging wound, forehead swelling and haematoma. CONCLUSION: The frontal osteoplastic flap still has a role in frontal sinus surgery. With minor technical modifications, this procedure may be performed with minimal complication and morbidity for patients with endoscopically inaccessible frontal sinus disease.

Characterising and quantifying outcomes in rhinology out-patients: measurements in the 'real world'.

AIMS: We aimed to evaluate a practical, computerised database for collection of patient-reported and clinical outcome data, introduced as a means of characterising our patient population and assessing the effect of our interventions. METHODS: A prospectively updated, computerised database was used to detail each patient's coded and structured diagnosis and clinical findings. Response to treatment was recorded using the Sino-Nasal Outcome Test 22 and changes in graded clinical examination findings. RESULTS: Data for 770 patients were prospectively entered into the database. Patients were grouped diagnostically as follows: rhinitis (20.4 per cent), chronic rhinosinusitis (12.2 per cent), chronic rhinosinusitis with polyps (24.7 per cent), anatomical anomaly (22.7 per cent), epistaxis (3.4 per cent) and 'other' (18.4 per cent). Following initial medical intervention, the greatest improvement in the Sino-Nasal Outcome Test 22 score was seen in the chronic rhinosinusitis with polyps group (-11.3), followed by the rhinitis group (-6.1) and the chronic rhinosinusitis group (-5.4). CONCLUSIONS: The tested rhinology database provides a simple, effective and practical tool for integrating the recording of clinical and patient-reported outcome measures during the out-patient visit. It enables characterisation of the patient population, and accurately monitors and records treatment responses.

Mapping surgical coordinates of the sphenopalatine foramen: surgical navigation study.

OBJECTIVES: To identify measurements that may help intra-operative localisation of the sphenopalatine foramen. DESIGN: The study used three-dimensional surgical navigation software to study radiological anatomy, in order to define the distances and angulations between identifiable bony landmarks and the sphenopalatine foramen. RESULTS: The distance from the anterior nasal spine to the sphenopalatine foramen was 59 mm (+/-4 mm; inter-observer variation = 0.866; intra-observer variation = 0.822). The distance from the piriform aperture to the sphenopalatine foramen was 48 mm (+/-4 mm; inter-observer variation = 0.828; intra-observer variation = 0.779). The angle of elevation from the nasal floor to the sphenopalatine foramen was 22 degrees (+/-3 degrees; inter-observer variation = 0.441; intra-observer variation = 0.499). CONCLUSIONS: The sphenopalatine foramen is consistently identifiable on three-dimensional, reconstructed computed tomography scans. Repeatable measurements were obtained. The centre point of the foramen lies 59 mm from the anterior nasal spine at 22 degrees elevation above the plane of the hard palate and 48 mm from the piriform aperture. We discuss how these data could be used to facilitate intra-operative location of the sphenopalatine foramen in difficult cases.

Spectrum of nasal disease in an asthma clinic: when is an ENT opinion indicated?

AIMS: To characterise the spectrum of nasal symptomatology and nasendoscopic abnormalities seen in patients attending an asthma clinic, and to relate these symptoms to the likelihood of finding nasendoscopic abnormalities which merit treatment. METHODS: Forty-three patients attending a problem asthma clinic were enrolled in an observational study. Cardinal nasal symptoms--obstruction, congestion, hyposmia, rhinorrhoea, sneezing, epistaxis or other symptoms--were graded as none (zero), mild (one), moderate (two) or severe (three), giving a maximum nasal symptom score of 21. Asthma symptoms and lung function were measured. Nasendoscopy was then performed. RESULTS: Obstruction was the most common cardinal nasal symptom (seen in 15 patients), the median nasal symptom score was 5.3 (range zero to 14) and only three patients had no nasal symptoms. There was no correlation between nasal symptom score and severity of asthma symptoms or forced expiratory volume in one second. Twenty-two patients had a normal appearance on ENT examination (median nasal symptom score four). The nasendoscopic abnormalities seen comprised polyps (n = 8; median nasal symptom score five), deviated nasal septum (n = 7; median nasal symptom score four), oedematous mucosa (n = 4; median nasal symptom score seven) and other abnormalities (n = 2). Individual nasal symptoms were poor predictors of individual nasal pathologies, with hyposmia the best individual predictor of any abnormality (positive predictive value 80 per cent). The presence of a combination of symptoms increased the likelihood of any nasendoscopic abnormality, with obstruction, rhinorrhoea and hyposmia together having a positive predictive value of 100 per cent. CONCLUSIONS: Nasal symptoms are much more frequent than structural abnormalities in patients attending a problem asthma clinic. The threshold for ENT referral should be lower when the patient complains of a symptom complex including hyposmia. Furthermore, concurrent hyposmia, obstruction and rhinorrhoea should be seen as an indication for ENT referral.

The role of ENT surgeons in snoring assessment: some prospective preliminary evidence.

OBJECTIVES: To determine (i) the prevalence of unsuspected upper aerodigestive tract disease in snorers, (ii) the diagnostic yield of routine flexible endoscopy and (iii) the relationship between symptoms of upper aerodigestive tract disease and examination findings in snorers. DESIGN: Prospective analytical cohort study. SETTING: Snoring clinic in Secondary Care Otolaryngology centre. PARTICIPANTS: Ninety-three patients referred with disruptive snoring. MAIN OUTCOME MEASURES: A structured history of upper aerodigestive tract symptoms was obtained by clinic interview. All patients underwent detailed ENT examination. Univariate analysis was undertaken on data collected. RESULTS: The prevalence of oropharyngeal and laryngeal pathology in the cohort was 3%. No unsuspected upper aerodigestive tract pathology was found on routine flexible endoscopy. A history of Hard Nasal Symptoms was an accurate predictor of underlying nasal pathology. CONCLUSION: The authors propose that the detailed examination of snorers by ENT specialists is unnecessary in the absence of Hard Nasal Symptoms, hoarseness or pain. We propose that a system of triage based on patient history could help identify the minority of snorers who require specialist assessment.

Endoscopic minimal access surgery in nasal and sinus tumours: lessons from initial experience.

The role of endoscopic techniques in the treatment of Nose and Para-Nasal Sinus tumours is the subject of wide debate. Technical advances in skills, imaging and instrumentation have resulted in Endoscopic Minimal Access Surgery gaining wide acceptance in the treatment of benign tumours. The place of endoscopes in malignant disease is more controversial. Defining the aims of endoscopic surgery is key to achieving a successful outcome. Experience with these new technologies and strategies should be gathered in a Clinical Network and Multi-Disciplinary Team setting, with planned long-term follow up. We report our initial experience of 33 patients managed with EMAS (27 curative, six debulking/palliative cases). Initial experience of the transition from the benign to malignant arenas supports a continued, cautious, structured evaluation of the endoscopic approach.

Woodruff's plexus.

OBJECTIVE: To identify the nature of Woodruff's plexus, which has been frequently mentioned in the rhinological literature but has never been properly characterised. STUDY DESIGN AND SETTING: A study using 21 cadaveric specimens, combining microdissection of the mucosa of the posterior part of the inferior meatus, Spalteholz 'clearing' of specimens injected with latex ink, and histological analysis of sections of the inferior meatal mucosa. RESULTS: Microdissection revealed a superficial plexus of thin walled vessels in the inferior meatus, which were also seen in cleared, injected specimens. Histological sections showed these vessels to be large, thin walled veins with very little muscle or fibrous tissue, within a thin mucosa relatively devoid of other structures. CONCLUSION: Woodruff's plexus is a venous plexus in the posterior part of the inferior meatus. SIGNIFICANCE: This is the first time Woodruff's plexus has been properly characterised. Whilst the significance of the plexus itself is uncertain, its long overdue identification as a venous plexus provides a platform for further study and discussion.

The epidemiology and chronobiology of epistaxis: an investigation of Scottish hospital admissions 1995-2004.

OBJECTIVES: This study aimed at investigating aspects of the epidemiology and chronobiology of emergency admissions with epistaxis in Scotland between 1995 and 2004. In particular, we sought to examine the epidemiology of hospital admission with epistaxis and effects of factors such as day of week, time of year and lunar cycle. DESIGN: A statistical analysis, in terms of descriptive statistics, logistical regression and linear regression, was carried out on data obtained from the Scottish Morbidity Records related to emergency Ear, Nose and Throat (ENT) admissions. SETTING AND PARTICIPANTS: All emergency inpatient admissions for Scottish residents to ENT wards in Scottish NHS hospitals during the 10-year period, between 1st January 1995 and December 31st 2004 were studied. This study only looked at admissions and thus excludes Accident and Emergency attendances caused by epistaxis. MAIN OUTCOME MEASURES: Age, gender, year, month and day of the week of admission were considered, as was relationship to the moon phase. RESULTS: During the study period, the mean daily admission rate with epistaxis was six. Epistaxis accounted for 33% of all ENT emergency admissions. The average age of non-epistaxis ENT emergency admission was 31 years. For epistaxis emergency admissions the median age was 70 years. There were fewer admissions in the summer months [August RR: 0.59 (95% CI: 0.54-0.65) P < 0.001]. There were more admissions at the weekends and on non-weekend public holidays [RR: -0.115 (95% CI -0.160-0.071) P < 0.001]. There was a trend towards a reduction in admission rates from the year 2001. Despite the fluctuations with season and weekday, there was no relationship with phase of the moon [RR: 0.98 (95% CI: 0.88-1.09) for day of the full moon compared with non-full moon weekday]. CONCLUSIONS: This study underlines the importance of epistaxis as the single most frequent emergency diagnosis in ENT. The frequency and patterns of admission show pronounced fluctuations. The observed increase in winter admissions confirms earlier work and may have implications for health resource allocation. Relationships between weekends/public holidays and increased admissions with epistaxis may correspond with social patterns of alcohol use (a known aetiological factor). The lunar cycle does not have an effect on the frequency of epistaxis admissions.

Endoscopic sphenopalatine artery ligation--when, why and how to do it. An on-line video tutorial.

KEYPOINTS: Endoscopic ligation of the sphenopalatine artery (ESPAL) has recently become the treatment of choice for refractory epistaxis. This paper reviews the background, indications and potential complications of ESPAL. The main focus of this article is an online video tutorial on the anatomy and surgical technique of ESPAL. Web links lead to video clips of operative steps and therefore this paper should be read in front of a computer with access to the Internet. To study the techniques the links detailed below should be followed. (For computers running RealPlayer software the .wmv extension in each of these links should be replaced with the .rm extension.) * Incision, http://nhsgg.org.uk/content/streams/Figure3.wmv * Flap elevation, http://nhsgg.org.uk/content/streams/Figure4.wmv * Pedicle location, http://www.nhsgg.org.uk/content/streams/Figure5.wmv * Clip application, http://www.nhsgg.org.uk/content/streams/Figure6.wmv.