Relationship of Lesion Location to Postoperative Steroid Use in Eosinophilic Chronic Rhinosinusitis.

OBJECTIVES: Eosinophilic chronic rhinosinusitis (ECRS) is known to recur after surgery. The treatment choice for recurrent ECRS, such as oral steroids or biological agents, must be chosen carefully, and identifying the lesion location may be useful. This study aimed to evaluate the postoperative course of ECRS patients and assess the relationship between endoscopic lesion location and postoperative oral steroid use. METHODS: Patients with chronic rhinosinusitis who underwent bilateral endoscopic sinus surgery from April 2018 to March 2020 were divided into two groups based on the presence or absence of oral steroid use after surgery. The primary endpoint was the lesion location on endoscopic findings during surgery: middle turbinate, middle meatus, superior turbinate, superior meatus, nasal septum, and sphenoethmoidal recess. Subjective symptoms, blood tests, and computerized tomography (CT) findings (Lund-Mackay score) were evaluated as secondary endpoints. RESULTS: Among 264 patients, 88 were diagnosed histologically with ECRS (mean 48.98 ± 1.40 years, 67 males/21 females). Twenty-three patients were steroid-using, 65 were steroid-free, and six stopped attending their appointments. Patients with sphenoethmoidal recess lesions were significantly more likely to require steroids (p = 0.019). There was a significant association between steroid use and younger age (p = 0.041), olfactory dysfunction (p = 0.021), and all sinuses (Frontal sinus: p < 0.001, Anterior ethmoid sinus: p = 0.002, Posterior ethmoid sinus: p = 0.011, Maxillary sinus: p = 0.018, Sphenoid sinus: p = 0.034, Total score: p < 0.001). CONCLUSION: A sphenoethmoidal recess lesion was a risk factor for requiring postoperative steroids. Young age, olfactory dysfunction, and preoperative severe CT findings were also significant risk factors. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:2511-2516, 2023.

Endoscopic modified transseptal bi-nostril approach for pituitary tumors. Efficacy of complex preservation of every turbinate and olfaction: A STROBE analysis.

AIMS: Endoscopic modified transseptal bi-nostril approach minimizes turbinate and olfactory mucosal invasion and ensures preservation of the turbinates and bilateral olfaction. The main objective of this study was to investigate the pre- and postoperative variations in olfactory function in patients using this approach, and the secondary objective was to investigate the complications associated with the surgical procedure. MATERIAL AND METHODS: This study is a single-center prospective cohort study using STROBE analysis. To completely protect the bilateral turbinates and olfactory epithelium, this procedure provided access to the sphenoid sinus by a transseptal approach via the left nasal cavity and by the olfactory cleft approach via the right nasal cavity without any turbinate resection. A T&T olfactometer was used to assess the mean recognition threshold of the left, right, and bilateral nasal passages before and after surgery, and complications associated with the surgical approach were investigated. OBJECTIVES: We included 27 patients who underwent endoscopic modified transseptal pituitary surgery with an olfactory and turbinate preservation approach at our hospital between April 2018 and December 2019. RESULTS: The mean postoperative recognition threshold of the right, left, and bilateral nasal cavities did not worsen (P<0.001 for all) relative to the preoperative values, and there was no difference in values between the right and left nasal cavities (P=0.85). The nasal turbinates were preserved in all patients during the study period, and no recurrence was observed. CONCLUSION: Our modified EETSA could be implemented as an approach for turbinate and olfaction preservation.

Maturation of odour identification ability and related factors in children.

BACKGROUND: Olfaction plays an important role in our daily and social lives, both as adults and as children. This study assessed whether the ability to identify odours increases with age, as well as the ability in various age groups and the factors involved. METHODS: The survey was performed in 2017 on 697 Japanese children (366 girls and 331 boys) aged 6â€"18 years who lived in Tsunan, Niigata Prefecture, Japan by using the 'Open Essence', a card-type odour identification test. We collected information regarding age, sex, and physical characteristic. We also inquired whether participants had siblings or if members of the family smoked, and whether they had conversations about odour at home. Statistical analysis was performed to evaluate the factors affecting odour identification abilities. RESULTS: The results showed that the odour identification abilities of children increase with age, and children who have daily conversations about odours at home have better odour identification abilities. CONCLUSIONS: Odour identification ability increases with age. In addition, our findings suggest that conversation may positively affect odour identification. Hence, it is important for children to be exposed to an environment where they develop an interest in smells for better growth of their olfactory identification ability.

Preemptive analgesia for endoscopic sinus surgery: a retrospective study.

BACKGROUND: Chronic rhinosinusitis (CRS) is a common disease, and endoscopic sinus surgery (ESS) is widely performed. However, there is no consensus regarding postoperative pain control after ESS, and postoperative opioid abuse is a problem in many countries. Acetaminophen is reportedly effective for postoperative pain control. Preemptive analgesia has received more attention lately, wherein pain is prevented before it occurs. In this study, we assessed the use of acetaminophen for preemptive analgesia during the perioperative period in ESS. METHODOLOGY: This is a retrospective study of 175 patients who underwent ESS, septoplasty, and bilateral inferior turbinate mucosal resection at our hospital from April 2016 to February 2018. In total, 82 patients received 1,000 mg of acetaminophen during surgery and 4 hours after the first dose, while 93 patients did not receive it routinely. We compared these two groups. The primary outcome was the need to use additional analgesics prescribed by the ward physician and the secondary outcomes included postoperative pain, postoperative bleeding, reoperation, blood pressure, and body temperature. RESULTS: The use of additional oral and intravenous analgesics was significantly reduced in the patients who received acetaminophen perioperatively. CONCLUSION: Preemptive analgesia during the perioperative period of ESS could lead to satisfactory postoperative pain control.

Airway intervention in cases of acute epiglottitis.

Airway intervention in cases of acute epiglottitis.Problem/objectives: In cases of acute epiglottitis, indications for airway intervention have not been established. In the present study, we reviewed patients with acute epiglottitis to identify clinical factors, which suggest airway intervention should be performed. METHODOLOGY: Patients with acute epiglottitis admitted to The Jikei University Daisan Hospital (Tokyo) from 2004 to 2013 were identified. Patients' characteristics, histories, laryngoscopic findings and laboratory findings were reviewed and analysed. RESULTS: Of the 83 patients (82 adults and one adolescent) in the sample, 16 (19%) underwent airway intervention and conservative treatment. The factors that were significantly more likely to have been present in patients who received airway intervention were odynophagia, drooling, hoarseness, muffled voice, dyspnoea, swelling of the posterior side of the epiglottis, less than 50% of the glottis area being visible with laryngoscopy, and a high white blood cell (WBC) count. The only factor that was shown by multiple logistic regression analysis to be distinctively predictive of airway intervention was "less than 50% of the glottis area being visible" (P = .000, odds ratio = 23.630, sensitivity = 86.6%, specificity = 78.6%, predictive accuracy = 85.2%). CONCLUSIONS: When considering whether airway intervention should be performed in cases of acute epiglottitis, the most important clinical factor is the laryngoscopic finding that "less than 50% of the glottis area being visible." Other important clinical factors to consider are odynophagia, drooling, hoarseness, muffled voice, dyspnoea, swelling of the posterior side of the epiglottis and a high WBC count.

Novel scoring system and algorithm for classifying chronic rhinosinusitis: the JESREC Study.

BACKGROUND: Chronic rhinosinusitis (CRS) can be classified into CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP). CRSwNP displays more intense eosinophilic infiltration and the presence of Th2 cytokines. Mucosal eosinophilia is associated with more severe symptoms and often requires multiple surgeries because of recurrence; however, even in eosinophilic CRS (ECRS), clinical course is variable. In this study, we wanted to set objective clinical criteria for the diagnosis of refractory CRS. METHODS: This was a retrospective study conducted by 15 institutions participating in the Japanese Epidemiological Survey of Refractory Eosinophilic Chronic Rhinosinusitis (JESREC). We evaluated patients with CRS treated with endoscopic sinus surgery (ESS), and risk of recurrence was estimated using Cox proportional hazard models. Multiple logistic regression models and receiver operating characteristics curves were constructed to create the diagnostic criterion for ECRS. RESULTS: We analyzed 1716 patients treated with ESS. To diagnose ECRS, the JESREC scoring system assessed unilateral or bilateral disease, the presence of nasal polyps, blood eosinophilia, and dominant shadow of ethmoid sinuses in computed tomography (CT) scans. The cutoff value of the score was 11 points (sensitivity: 83%, specificity: 66%). Blood eosinophilia (>5%), ethmoid sinus disease detected by CT scan, bronchial asthma, aspirin, and nonsteroidal anti-inflammatory drugs intolerance were associated significantly with recurrence. CONCLUSION: We subdivided CRSwNP in non-ECRS, mild, moderate, and severe ECRS according to our algorithm. This classification was significantly correlated with prognosis. It is notable that this algorithm may give useful information to clinicians in the refractoriness of CRS before ESS or biopsy.

Mucosal eosinophilia and recurrence of nasal polyps - new classification of chronic rhinosinusitis.

BACKGROUND: Eosinophils and nasal polyps are believed to affect the surgical outcome of chronic rhinosinusitis (CRS). CRS is classified based on the presence of nasal polyps in western countries. The majority of patients with CRS with nasal polyps (CRS with NP) are characterized by predominantly eosinophilic inflammation. However, Asian patients with CRS with NP show characteristics indicative of neutrophilic inflammation. Therefore, are eosinophils or nasal polyps more important for the classification of CRS? METHODS: A prospective cohort study conducted from April 2007 to March 2008 classified patients with CRS based on the presence of nasal polyps and mucosal eosinophilia. The recurrence rate of nasal polyps was compared between the groups. Recurrence rate was analysed as a time-dependent variable by the Kaplan-Meier method. RESULTS: Eosinophilic inflammation was found in 59.6% of patients with CRS with NP. Patients with mucosal eosinophilia had higher polyp recurrence rate than patients without mucosal eosinophilia, whereas patients with nasal polyps did not have higher polyp recurrence rate than patients without nasal polyps. CONCLUSIONS: Presence of mucosal eosinophilia is a more important factor than nasal polyps for classifying CRS in terms of the surgical outcome.

Endoscopic transnasal approach to the pituitary lesions using a navigation system (InstaTrak system): technical note.

The endoscopic transnasal approach has become a procedure of choice for the surgical management of pituitary lesions. However, in conventional endoscopic transnasal surgery, the surgeon may become disorientated to the actual operating position. In our series, 31 patients have undergone an endoscopic transnasal approach to the pituitary lesions with the use of the navigation system InstaTrak for real-time imaging. This image guidance system proved valuable for anatomic localization during pituitary surgery. We have reduced the average surgical time, and improved patient outcome. As consequence, complications during surgery should decrease and safety should increase. Intraoperative image guidance is expected to have major advantageous effects on pituitary surgery by allowing the surgeon to remove pathology more efficiently. As this system is improved technically and surgeons become more proficient in its use, there should be better postoperative outcomes.

Endoscopic transnasal approach to the pituitary lesions using navigation system (InstaTrak System).

Endoscopic transnasal approach has become a procedure of choice for the surgical management of pituitary lesions. However, in conventional endoscopic transnasal surgery, the surgeon may become disorientated to the actual operating position. In our series, 47 patients have undergone an endoscopic transnasal approach to the pituitary with the use of the navigation system called InstaTrak for real-time imaging. This image guidance system proved valuable for anatomical localization during pituitary surgery. We have reduced the average surgical time, and improved patient outcome. As a consequence, complications during surgery should decrease and safety should increase. Intra-operative image guidance is expected to have major advantageous effects on pituitary surgery by allowing the surgeon to remove lesions more efficiently. As this system is improved technically and surgeons become more proficient in their use, there should be better postoperative outcomes.

Endoscopic transethmosphenoidal approach for pituitary tumors with image guidance.

The advantages of endoscopic transethmosphenoidal surgery for pituitary tumors using a navigation system were reported. The surgical technique was as follows. First, sphenoidal sinuses were opened via the bilateral ethmoidal sinuses and the olfactory clefts. Then the septum of the sphenoidal sinuses was resected. Next, an endoscope was inserted via the left nasal cavity and fixed in place. The tumor was then removed via the right nasal cavity. Our approach for pituitary tumors provided sufficient working space and permitted the surgeon to carry out the procedure using both hands. In addition, use of the InstaTrak System made it possible to recognize the orientation of the surgical field in the sella turcica. Thus, the tumor could be resected more easily and safely. It is concluded that this approach will be particularly useful for patients with narrow nasal cavities or poor development of the paranasal sinuses.

[Efficacy of endoscopic transethmoidal.transsphenoidal surgery for pituitary tumors].

Endoscopic transethmoidal.transsphenoidal surgery was performed on 30 patients with pituitary tumors, and the usefulness of this procedure was evaluated. As with conventional endoscopic intranasal surgery, the ethmoidal sinuses were opened and a broad window was created in the ethmoidal sinus from the directions of the middle meatus and the olfactory cleft. Then an endoscopic washing device was attached to a 0 degree or 30 degrees rigid endoscope and it was immobilized in the left nasal cavity with an endoscope immobilization apparatus. Removal of the tumor was then started from the right side by a bimanual technique. Based on the results, this surgical procedure was judged to be useful for the following reasons (1) it makes it easy to carry out the operative manipulations even in a narrowed nasal cavity, thereby reducing the overall time required for surgery, and (2) it is possible to prevent postoperative deformities of the nasal cavity morphology caused by pressure on its lateral wall. In additional, (3) the surgical wound can be observed, and CSF leakage can be repaired immediately after completion of the operation. Corrective surgery can be performed on an outpatient basis early after the initial operation to correct postoperative deformities of the nasal paranasal cavities, which might later cause nasal obstruction or an olfactory disturbance. Finally, (4) employing the route of endoscopic transethmoidal.transsphenoidal surgery facilitates the performance of a second operation soon, or even several months, after the first operation. A second operation may be necessary in the event of recurrence of the pituitary tumor or complication by chronic sinusitis. On the basis of our experience in the this study, we conclude that our method of endoscopic transethmoidal.transsphenoidal surgery will be useful for reducing invasiveness in the nasal cavities and achieving maximum prevention of postoperative complications. In order to fulfill its potential, neurosurgeons will need to master forceps techniques in the visual field provided by the endoscope and to cooperate with otorhinologists who are skilled in endoscopic techniques.

Association of bronchopneumonia with sinusitis due to Bordetella bronchiseptica in an experimental rabbit model.

An animal model for rhinogenic sinusitis was developed in rabbits naturally colonized with Bordetella bronchiseptica. It was found that ostial occlusion predisposes the sinus to invasion with this opportunistic bacterium and subsequent sinusitis as a result of reduced local host defense. In addition to the inflammatory lesions in the sinus, bronchitis and pneumonia were found in 84% of the experimental rabbits, suggesting that ostial dysfunction can also contribute to infectious disease of the lower respiratory tract. In such a model it is possible to study the significance of asymptomatic carriage of potential pathogens after ostial occlusion.

[Endoscopic endonasal surgery with image-guidance].

We evaluated the advantages and disadvantages of image-guided endoscopic endonasal surgery for various diseases. Thirty-three patients, including 8 with chronic sinusitis, 14 with paranasal cysts, 1 with paranasal tumor (biopsy), 1 with sellaturcial cyst (Rathke's cleft cyst) and 9 with pituitary tumors were endonasally operated on from September 1998 to May 1999, with an electromagnetic navigation system, The Insta Trak (Visualization Technology Inc. USA). The Insta Trak system is composed of a computer, a metal probe with a nonmetallic suction tube attachment, and a soft-type headset with an electromagnetic sensor. This freehand, armless system compensates well for patient's head movement during surgery, and precludes the need for head fixation. Either straight or curved suction tube (probe) can be used to access almost of all pathological sites in the sinus cavity. Location of the metal probe is displayed on the computer moniter as an intersection point on the axial, coronal and sagital CT images. In all cases, Insta Trak showed the surgeon the appropriate location and direction of each lesion. The Insta Trak also indicated the location of the orbit, optic canal, nasolacrimal duct and/or skull base, thus, preventing intraoperative complications. When the anatomy was distorted by previous surgery and/or when there was uncontrollable bleeding from a severe lesion so that the surgeon had difficulty finding the proper orientation, the usefulness of image-guided surgery was sufficiently recognized. However, the following disadvantages were also pointed out. An additional 15 to 20 minutes is needed for equipment set up and operation, unless the surgeon and the operation room staff are familiar with the machine. The patient's CT image used for navigation relies on data obtained preoperatively, that is to say, it can not reflect morphological changes produced during surgery. Moreover, the surgeon must consider possible errors of the navigational point that may result in the headset during surgery, as well as, errors the machine may originally possess. The image-guided system successfully integrated the most up-to-date computer technology with a surgeon's anatomical knowledge for improved treatment of endoscopic endonasal surgery. However, we also concluded that the system should be used as a surgical supporting device for safer and more adequate procedures.

Saccharin test of maxillary sinus mucociliary function after endoscopic sinus surgery.

OBJECTIVES: To determine the usefulness of the saccharin time (ST) test for evaluating the mucociliary function of the maxillary sinus after endoscopic sinus surgery (ESS) for chronic sinusitis. METHODS: This study was conducted on 88 maxillary sinuses of 74 patients after ESS. The maxillary sinus fontanel was broadly opened via the middle meatus using an endoscope, and a saccharin granule was adhered to the bottom of the maxillary sinus mucosa The time until the patient recognized the sweet taste was recorded. Before the ST test, the bilateral maxillary sinuses were classified into the following four groups on the basis of the post-ESS severity of mucosal edema and swelling as revealed by endoscopic observation: normal (45 sinuses), mild mucosal edema and swelling (24), moderate mucosal finding (14), and severe mucosal finding or filling of the sinus with a polyp(s) (5). RESULTS: The mean ST values in the normal group and the groups with mild, moderate, and severe mucosal edema and swelling were 35.7, 38.1, 63.6, and 88.0 minutes, respectively. Thus the ST increased with the post-ESS severity of the mucosal lesion. However, for the group with mild mucosal edema and swelling, scanning electron microscopic observation of three maxillary sinuses in which the ST exceeded 120 minutes and four sinuses in which the ST was 40 minutes revealed extensive cilia loss in the former sinuses, but not in the latter. A second post-ESS endoscopic observation was performed in 17 patients, revealing improvement in 11 sinuses, no change in 5 sinuses, and aggravation in 1 sinus (compared with the initial test). The ST test was also repeated, revealing that the ST became shorter in most of the endoscopically improved sinus group. However, a few sinuses showed a discrepancy between the change in the endoscopic findings and the ciliary function (ST). CONCLUSION: Measurement of the maxillary sinus ST is a simple, accurate, and useful technique for assessing the post-ESS mucociliary function in conjunction with endoscopy, and the information gained can help in deciding subsequent therapy.

Experimental nasal intubation: a study of changes in nasoantral mucosa and bacterial flora.

OBJECTIVES: To investigate the local effects in a nasal cavity and its adjacent sinuses of long-term detention of an endonasal tube, with special attention to inflammatory pathology and microbiology. STUDY DESIGN: Experimental rabbit study. METHODS: Four groups of 4 rabbits, in all 16, were unilaterally nasally intubated and evaluated macroscopically, histopathologically, and bacteriologically after 1, 2, 4, and 8 weeks, respectively. RESULTS: At first, in the 1- and 2-week groups to the 4-week group, histopathology, such as degeneration of olfactory mucosa, squamous cell metaplasia, and polyp formations, was observed together with frequent opportunistic bacterial findings in the nasal cavity. Later, in the 4- and 8-week groups, inflammatory mucosal changes, such as septal increase of connective tissue, goblet cell hyperplasia, and epithelial invaginations, were found in the nasal cavity containing a tube. A concomitant increase was found of commensal bacteria adjacent to the tube and the similar bacterial findings in the ipsilateral maxillary sinuses. However, there were no signs of inflammatory reactions in the sinuses. CONCLUSIONS: Our investigation points to the tube as the cause of local goblet cell hyperplasia with an increased mucus production, and as a food source for the commensals with a marked increase of the amount of bacteria. The positive bacterial cultures from the maxillary sinuses might be considered to be colonization. However, because of the possibility of contamination, improved sampling techniques are required, as are further studies.

Microvasculature, blood flow, and vasoreactivity in rabbit sinus mucosa after surgery.

OBJECTIVES: To study the circulatory integrity of the sinus mucosa following surgery, the vascular anatomy, blood flow, and vasoconstrictor response of the regenerated microcirculatory network were analyzed. STUDY DESIGN: Forty-six New Zealand White rabbits were operated on unilaterally with either a modified radical operation (MRO) or middle meatal antrostomy (MMA), using the nonoperated sinus for control purposes. After surgery, the animals were left to heal for 1 month. METHODS: Vascular casts were prepared with a low-viscosity methyl methacrylate resin and studied by scanning electron microscopy. Blood flow was measured by means of radiolabeled microspheres (tin 113 [113Sn]). The vasoconstrictor response to oxymetazoline at increasing concentrations was measured with laser Doppler flowmetry. RESULTS: The number of vessels increased significantly in the regenerated mucosa. The vascular casts displayed a rich microcirculation with local signs of angiogenesis. However, there was no difference in blood flow between the operated cavities and their control sides. Following MRO the regenerated mucosa was more sensitive to the vasoconstrictor effect of oxymetazoline, compared with the control side. This difference was not evident in the MMA-operated sinuses. CONCLUSIONS: In this model, surgery does not seriously interfere with the sinus blood flow, although the regenerated mucosa did display an altered vasoreactivity. These findings should be considered in relation to the effects of surgery intended to limit local inflammation and to ensure the ventilation of the sinuses.

Lectin expression during wound healing of the rabbit sinus mucosa: a study of regenerating epithelium and early polyp formation.

Lectin expression during wound healing of the rabbit sinus mucosa was examined. Positive UEA-I staining was evident on squamous or cuboidal as well as columnar regenerating epithelial cells (RE cells). PNA staining of columnar RE cells first became evident after neuraminidase treatment, while squamous or cuboidal RE cells stained positively with PNA alone. Fucosylation within RE cells thus occurred from a relatively early period, and sialylation followed at later stages. Ingrowing epithelial cells of early polyp formation stained negatively with UEA-I, indicating that unfucosylated RE cells may represent aberrant cellular behavior. We concluded that these patterns of lectin staining indicate a functional maturation as well as an integration of regenerating mucosa.

Changes in glycoconjugate expression of the sinus mucosa during experimental sinusitis: a lectin histochemical study of the epithelium and goblet cell development.

Lectin expression in both normal and inflamed sinus mucosa in rabbit was investigated histochemically. A different staining pattern was observed in the inflamed mucosa, i.e. the degree of staining reactivity with Canavalia ensiformis (ConA) decreased, whereas staining with Ulex europaeus agglutinin-I (UEA-I), Arachis hypoga (PNA) with neuraminidase pretreatment and Triticum vulgaris (WGA) intensified, indicating an enhanced fucosylation as well as sialylation. Goblet cells were stained with UEA-I, WGA, PNA and PNA with neuraminidase pretreatment, but scarcely with ConA. Positive PNA staining of basal cells and epithelial secretory granules was observed in the inflamed mucosa, especially close to areas where goblet cell development was prolific. It was therefore assumed that basal cells can differentiate into goblet cells-through epithelial secretory cells accompanied by sialylation and/or sulphonation of their mucins. It is concluded that the changes in glycoconjugate expression as well as goblet cell development in the inflamed mucosa are of importance for both local host resistance and defence mechanisms against microorganisms during the early stages of the inflammatory process.

The anti-inflammatory effect of fusafungine during experimentally induced rhinosinusitis in the rabbit.

The short-term effects of local intranasal administration of fusafungine were studied for its anti-inflammatory and antimicrobial properties against experimentally induced bacterial rhinosinusitis. The maxillary sinuses of 20 rabbits were infected with encapsulated Streptococcus pneumoniae after mechanical occlusion of each animal's anatomic ostium. Either fusafungine solution or placebo was administered as a nasal spray through the nostrils twice daily for 10 days. Histopathological grading of inflammation, biochemical assay of inflammatory mediators, and the number of bacterial species isolated from the nasal cavities all showed significant recovery from inflammation after fusafungine treatment. The beneficial effects of fusafungine on inflamed sinus mucosa may possibly also be attributable to an initial alleviation of inflammation in the nasal cavity, which permitted entry of the drug to the sinus cavity through a partially reopened ostium. A reciprocal relationship between nasal and sinus reactivity involving generalization of inflammation and recovery was also thought to be of importance. The present findings indicate that local applications of fusafungine may effectively improve clinical conditions producing rhinitis and sinusitis.