Is Nasal Endoscopy of Diagnostic Value in Chronic Rhinosinusitis Without Nasal Polyps?

Endoscopic examination of the nasal cavity is an integral part of the assessment of patients with chronic rhinosinusitis. However, the benefit gained by performing endoscopy with respect to the patient's medical condition has not been completely assessed. We conducted a prospective cohort in an academic medical center. Thirty-nine patients diagnosed with chronic rhinosinusitis, without polyps, whose ailment was managed conservatively with no surgical intervention. All patients underwent nasal endoscopy, a computed tomography (CT) scan rated for Lund-MacKay score, and completed a sino nasal outcome test (SNOT)-20 questionnaire. This same evaluation was repeated 6 weeks following medical treatment. The CT scan and SNOT-20 questionnaire were independent parameters to evaluate the endoscopy score in each nasal passage. Thirty-nine (28 females) patients completed the follow-up period. A total of 156 endoscopic evaluations were performed, in which 74 nasal cavities were found to have significant pathology and 82 were either normal or displayed mild pathology. The correlation with the Lund-MacKay score was poor with a positive predictive value of 68.9% (31.1% false positive and 28% false negative). However, while looking at the SNOT-20 score, corrected for repeated measures, a higher endoscopy score was associated with a higher SNOT-20 score (odds ratio = 3.53, 95% confidence interval = 1.54-8.09, P = .003). Patients with higher endoscopy scores had a greater probability for exhibiting severe symptoms. However, we could not demonstrate a strong correlation between nasal endoscopy findings and CT scan scores. Therefore, with respect to patients with chronic rhinosinusitis without polyps, nasal endoscopy could be utilized as a beneficial objective tool.

Upper airway involvement in bronchiectasis is marked by early onset and allergic features.

The association of bronchiectasis with chronic rhinosinusitis (CRS) has been reported. However, apart from primary ciliary dyskinesia (PCD) and cystic fibrosis (CF), predisposing conditions have not been established. We aimed to define clinical and laboratory features that differentiate patients with bronchiectasis with upper airway symptoms (UASs) and without PCD from patients without UASs. We reviewed charts of adults with bronchiectasis, excluding CF and PCD. UASs were defined as nasal discharge most days of the year, sinusitis or nasal polyps. Laboratory data included IgG, total IgE, blood eosinophils, sputum bacteriology and lung function. A radiologist blinded to UAS presence scored bronchiectasis (Reiff score) and sino-nasal pathology (Lund-Mackay score). Of 197 patients, for the 70 (35%) with UASs, symptoms started earlier (34±25 versus 46±24 years; p=0.001), disease duration was longer (median 24 versus 12 years; p=0.027), exacerbations were more frequent (median 3 versus 2 per year; p=0.14), and peripheral blood eosinophil (median 230 versus 200 µL-1; p=0.015) and total IgE (median 100 versus 42 IU·mL-1; p=0.085) levels were higher. The sinus computed tomography score was independently associated with exacerbations, with 1 point on the Lund-Mackay score associated with a 1.03-fold increase in the number of exacerbations per year (95% CI 1.0-1.05; p=0.004). These findings may implicate a higher disease burden in patients with UASs. We hypothesise that UASs precede and may in some cases lead to the development of bronchiectasis.

The role of surgery in necrotizing otitis externa.

This retrospective case review describes a subset of 5 patients with necrotizing otitis externa (NOE) with a refractory disease course who underwent surgery as part of their management plan between 2008 and 2013. Surgery promoted the cure of 4 of the 5 patients, and a fungal pathogen was recovered in 4 of 5 surgical samples. We conclude that surgery may be a necessary diagnostic and treatment adjunct in selective cases of NOE, especially in patients with a refractory disease course or with a suspected fungal etiology.

Idiopathic nasal bone osteitis: A preliminary report on a recently recognized entity.

Osteitis of the nasal bones is a rare disease; when it occurs, it usually has a known etiology. To the best of our knowledge, idiopathic nasal bone osteitis (NBO) has not been described before. We conducted a study to analyze the behavior of idiopathic NBO and its outcome and to determine a cutoff level for diagnosis using technetium-99m-methylene-diphosphonate (Tc-MDP) bone scanning. This retrospective, controlled analysis involved 9 women (mean age: 44 yr) who had been admitted to an otolaryngology department in Israel with idiopathic NBO over a 5-year period. Clinical evaluation, isotopic evaluation, and computed tomography were done. A lesion-to-nonlesion ratio was calculated between an area of interest on the nasal bone and a reference point (L/R ratio). The same ratio was calculated for a control group of 20 subjects. All the Tc-MDP scans in the study group were suggestive of osteitis. Intravenous antibiotic treatment was effective in all cases. A high degree of accuracy was achieved with cutoff L/R ratios of 2.05 for planar views and 2.34 for single-photon emission computed tomography views.

Clinical utility of a polymerase chain reaction assay in culture-negative necrotizing otitis externa.

OBJECTIVE: This study describes a subset of necrotizing otitis externa (NOE) patients with a refractory disease and negative cultures. In these cases, we decided to use a polymerase chain reaction (PCR) assay from surgically obtained tissue under sterile conditions to improve pathogen detection sensitivity. STUDY DESIGN: Retrospective case review. SETTING: Academic medical center. PATIENTS: Nineteen consecutive patients diagnosed with NOE between January 2008 and January 2014 inclusive. Three patients of this cohort presented a culture-negative disease. INTERVENTIONS: Diagnostic. MAIN OUTCOME MEASURES: Positive detection of pathogens using a PCR assay in cases with a complicated course of NOE and clinical resolution of the disease after targeted therapy according to PCR results. RESULTS: Surgical samples were obtained under sterile conditions from three patients with negative cultures and a refractory disease course of NOE. PCR assays were performed using pan-bacteria and pan-fungi protocols. In all three samples, a positive result for a fungal pathogen was recorded and followed by successful empirical targeted therapy. CONCLUSION: Patients who present with a refractory culture-negative NOE should be suspected as suffering from a fungal disease. The PCR assay may be an important laboratory adjunct in detecting pathogens responsible for NOE and can aid to promote therapy and disease resolution.

Primary NK/T-cell lymphoma of the larynx.

Laryngeal extranodal non-Hodgkin lymphoma is uncommon, accounting for less than 1% of all laryngeal neoplasms; the B-cell phenotype is predominant. Lymphomas outside the nasal cavity are rare and highly aggressive. We present a case of primary natural killer T-cell (NK/T-cell) lymphoma of the larynx that arose in a 45-year-old man. Because only a limited amount of data is available on laryngeal NK/T-cell lymphoma, the mainstay of treatment remains unclear, although some data suggest that radiotherapy alone is the best option. Our patient was treated with chemotherapy and radiotherapy, and he remained in remission 2 years later.

A case of nasogastric tube perforation of the nasopharynx causing a fatal mediastinal complication.

Iatrogenic nasopharyngeal perforations secondary to improper nasogastric tube insertion probably occur more frequently than has been reported. Our review of the literature found very few cases. We report the case of a 79-year-old woman who died of mediastinal complications following the improper insertion of a nasogastric tube that resulted in a nasopharyngeal perforation. We also review the proper technique for inserting these tubes.

Hemifacial spasm associated with otitis media with effusion: a first reported case.

Hemifacial spasm is a condition consisting of unilateral paroxysmal involuntary contractions of the muscles innervated by the facial nerve. The most common etiology is a vascular loop compression at the root exit zone of the nerve. We present here a first reported case of hemifacial spasm associated with otitis media with effusion, in a 6-year-old girl, which was relieved immediately following ventilation tubes insertion. A proposed mechanism is described.

Indications for the Caldwell-Luc approach in the endoscopic era.

OBJECTIVE: Caldwell and Luc described the Caldwell-Luc operation more than 100 years ago as the surgical treatment for maxillary sinus disease. During the last decades less radical interventions using endoscopic approach have mainly replaced the classical procedures done for chronic and recurrent maxillary sinusitis. STUDY DESIGN AND SETTING: Between 1991 and 2002, 62 patients had the Caldwell-Luc approach for different indications. RESULTS: Twenty (32%) patients had chronic sinusitis, 16 (26%) patients had inverted papilloma, 9 (15%) patients had suffered from nasal polyposis, 4 patients (6%) had dentigerous cyst, 4 (6%) patients had fungal ball, and 9 (15%) patients were operated for other indications. CONCLUSIONS: The use of this surgical approach is rational in cases of fungal disease and in endoscopic medial maxillectomy for treating inverted papilloma. In all other cases, the preferred approach should now be endoscopic.

Classification of fungal sinusitis in immunocompetent patients.

OBJECTIVE: The objective of this study was to review the subgroup classification of fungal sinusitis in immunocompetent patients. METHODS: The study design included 19 immunocompetent patients with fungal sinusitis who were operated on between 1993 and 1998. RESULTS: Ten of 19 patients showed a fungus ball. They underwent a limited surgical endoscopic procedure, and no further treatment was needed. Four patients had allergic fungal sinusitis and were treated postoperatively with irrigation, topical steroids, and oral steroids in 2 patients as well. Five patients had chronic sinusitis with significant bone erosion. All 5 underwent an extensive endoscopic procedure and were treated postoperatively by repeated irrigation, endoscopic cleaning, and no antifungal preparation. Two patients of this group are reported broadly. CONCLUSIONS: Fungal sinusitis in immunocompetent patients is not a rare condition and can be divided into 3 categories: 1) fungus ball, 2) chronic erosive (noninvasive) fungal sinusitis, and 3) allergic fungal sinusitis. The symptomatology, treatment, and prognosis varied significantly among the 3 different categories.

Acyclovir in the treatment of Ramsay Hunt syndrome.

Ramsay Hunt syndrome is an herpetic disease with ominous prognosis regarding the facial nerve. Treatment with acyclovir, a well-known virostatic agent, has been given in a small number of patients in recent years with excellent results. We report on the administration of acyclovir intravenously for 7 days in 31 patients with Ramsay Hunt syndrome, with overall recovery rate of 82.6%. There were no side effects regarding this treatment.

Acyclovir in the treatment of idiopathic sudden sensorineural hearing loss.

BACKGROUND: Idiopathic sudden sensorineural hearing loss (ISSNHL) is a vexing problem that continues to pose a diagnostic and therapeutic enigma for the otologist. The aim of the study, adopting the viral theory, was to discover whether patients with ISSNHL would benefit from early treatment with acyclovir and hydrocortisone compared with patients treated by hydrocortisone alone. METHODS: Sixty patients with ISSNHL were treated in a prospective controlled randomized manner. Patients were seen within 7 days of onset and were divided randomly into 2 groups. The study group patients were treated with acyclovir and hydrocortisone, whereas those in the control group were treated with hydrocortisone alone. RESULTS: We compared the 2 groups before and after treatment regarding SRT, mean hearing level at each frequency, speech reception threshold improvement, gender, age, tinnitus, and balance complaints. The overall improvement was 78%. CONCLUSION: We conclude that there probably is no benefit from the addition of acyclovir in the treatment of ISSNHL.

Functional endoscopic sinus surgery in the treatment of massive polyposis in asthmatic patients.

The association between asthma and sinonasal disease has been known for years. Effective treatment of sinonasal disease, which is one of the factors that exacerbate asthma, may also improve and stabilize the asthmatic condition. This study examines the outcome of functional endoscopic sinus surgery (FESS) on asthmatic patients with massive nasal polyposis. Thirty-four asthmatic patients were included in the study. All were operated on in our department and were analysed for pre-operative data regarding their asthma and sinonasal disease. A questionnaire regarding subjective evaluation of asthma and sinonasal status was presented to the patients, and objective evaluations, including nasal endoscopy and spirometry, were performed. Follow-up endoscopy revealed satisfactory results in 88 per cent, with positive correlation to the patients' subjective assessment of nasal status. No such correlation was found with regard to subjective and objective assessment of asthma: a small group of patients had completely clean sinonasal cavities with no perceived improvement in their asthmatic condition. The use of prednisolone and bronchodilators was significantly reduced post-operatively. However, in a subgroup of 13 patients followed at the asthma clinic, who had adequate pre-operative and post-operative data, there was no difference in their pre- and post-operative asthma condition. Seven had minimal improvement and in six there was a definite worsening of their asthma; nevertheless, nasal breathing and quality of life improved in most patients. The mean follow-up was 2.1 years. Thus, we conclude that in this study FESS does not improve asthma, but does improve the quality of the life of the patient.