Endoscopic management of frontal sinus mucoeceles with anterior table erosion.

OBJECTIVE: To describe the endoscopic management of frontal sinus mucoeceles with anterior table erosion. Previous hardware exposure and subsequent contour defects were also assessed. DESIGN: Retrospective case series. METHODS: Thirty-seven patients (mean 48 yrs, range 20-78) with frontal sinus mucoeceles and anterior table erosion, endoscopically managed in a tertiary care setting, were reviewed. The demographic data, defect size, surgical technique, presence of exposed hardware, outcomes, and clinical follow-up were collected for outcome assessment RESULTS: The average follow-up was 32.6 months (range, 6-73). The overall long-term success rate with our initial endoscopic approach was 92% (34/37). The average size of anterior table defects was 181 mm2 (4-1155). Twelve patients had prior osteoplastic flaps (OPF) with obliteration and 57% (21/37) had previous endoscopic sinus surgeries. Ten patients with prior OPF operations had hardware exposed within the sinus from previous surgeries. Two patients eventually required an OPF with fat obliteration. Most defects were either unnoticeable or cosmetically acceptable to the patients. Only one patient required a contouring plate six months after the procedure. Ninety percent of patients were successfully managed with exposed hardware left in situ. CONCLUSIONS: Endoscopic marsupialization of frontal sinus mucoeceles with anterior table erosion has a high success rate with a good cosmetic outcome, often without routine reconstruction. Revision cases and those with exposed hardware did not prevent successful management.

Factors contributing to failure in endoscopic skull base defect repair.

BACKGROUND: Endoscopic repair of skull base (SB) defects is successful in over 90% of cases. Certain factors may contribute to failure of SB repair techniques or need for secondary repair. METHODS: Five-year retrospective review of endoscopic SB defect repairs performed by a single surgeon. RESULTS: Eighty-nine patients undergoing 110 procedures to repair 97 SB defects were evaluated. Etiology of defects included surgical/iatrogenic (64%), spontaneous (17%), traumatic (12%), congenital (6%), and idiopathic (1%). Defects occurred in the sella (41%), sphenoid sinus (18%), ethmoid roof (17%), olfactory cleft (16%), frontal sinus/recess (6%), and middle cranial fossa (2%). Sixty-three patients (71%) underwent primary SB defect repair and 26 patients underwent secondary repair (29%). In revision cases, mean number of prior repair attempts was 1.5 (range, 1-4). Factors potentially contributing to need for secondary SB defect repair included inability to localize SB defect (p =0 .008), development of new SB defect, prior sinus or SB surgery (p < 0.001), prior craniotomy (p < 0.001), prior radiation therapy (p = 0.002), and intracranial infection (p = 0.023). SB defects were successfully closed in 83 patients overall (93%), with success achieved in 97% of primary patients and 85% of secondary patients. Of failures, 3 patients required craniotomy for defect closure, 2 patients underwent permanent cerebrospinal fluid (CSF) diversion, and 1 patient has persistent CSF rhinorrhea. CONCLUSION: Although endoscopic repair of SB defect remains largely successful, certain factors should alert the surgeon to the potential for failure of repair or need for secondary SB defect repair.

Comparison of techniques for transsphenoidal pituitary surgery.

BACKGROUND: The aim of this study was to compare three different techniques for transsphenoidal pituitary surgery: (1) sublabial transseptal approach with microscopic resection, (2) transnasal transseptal approach with endoscopic resection, and (3) endoscopic approach with endoscopic resection. METHODS: We performed a retrospective review of 50 pituitary surgeries performed by the same neurosurgeon. Demographic, radiographic, and clinical data were collected. RESULTS: Fifteen patients underwent sublabial approach with microscopic tumor resection, 21 patients underwent the transnasal approach with endoscopic resection, and 14 patients underwent the completely endoscopic technique. There were a total of 20 complications in the sublabial group, 13 transnasal complications, and 6 endoscopic complications. Cerebrospinal fluid leak incidence was 53% in the sublabial approaches, 47% transnasal, and 28% in the endoscopic patients. Diabetes insipidus was encountered in 33% of sublabial approaches, 5% of transnasal approaches, and 7% of endoscopic approaches. Lumbar drains were required in 40% of sublabial approaches, 38% of transnasal approaches, and 7% of endoscopic approaches. Nasal packing was used in 100% of sublabial and transnasal approaches and 0% of endoscopic approaches. Mean recurrence rate and follow-up was sublabial in 6.6% (50 months), transnasal in 9.5% (11 months), and endoscopic in 0% (7 months). Average hospital stay for sublabial approaches, transnasal approaches, and endoscopic approaches was 8.3, 6.2, and 3.4 days, respectively (p < 0.05). CONCLUSION: Transsphenoidal pituitary surgery has evolved over the past several decades, because advances in technology have been the catalyst for minimally invasive surgeries. Less invasive approaches, such as the transnasal approach with endoscopic resection of tumor and the completely endoscopic .technique have less morbidity and a shorter hospital stay than traditional sublabial approaches. Continued follow-up is needed to confirm long-term benefits and similar recurrence rates.

Surfactant protein A and D in human sinus mucosa: a preliminary report.

INTRODUCTION: Surfactant-associated proteins (SPs) play a crucial role in the innate defense system and serve as the initial step in the immune response to inhaled pathogens. SP-A and SP-D expression and function are altered in a variety of inflammatory and infectious diseases of the lungs, such as asthma, allergies, and cystic fibrosis, but their presence and function in the sinonasal cavity has not been investigated. The objective of this study was to test our hypothesis that SP-A and SP-D are present in the human sinus. MATERIALS AND METHODS: Sinus mucosal biopsies were performed in 8 patients undergoing endoscopic sinus surgery for chronic rhinosinusitis with nasal polyposis, pituitary tumors, and cerebrospinal fluid leak repairs. Expression of SP mRNA and protein by the sinus mucosa was detected by RT-PCR and immunoblot analysis, respectively. RESULTS: Analyses of mucosal biopsies from these patients revealed the presence of SP-A and SP-D mRNA and protein in all specimens. CONCLUSION: SP-A and SP-D are expressed in both normal and diseased human sinus tissue. Understanding the role of SPs in diseased and healthy states may elucidate their possible roles in innate immunity in the upper airway and allow us to develop novel treatments for sinonasal pathologies.

Innate and adaptive mediators in cystic fibrosis and allergic fungal rhinosinusitis.

BACKGROUND: Surfactant-associated proteins (SP) A and D are both innate immunity mediators and produced in normal and diseased sinus mucosa. Cystic fibrosis (CF) is associated with Th1 adaptive inflammation whereas allergic fungal rhinosinusitis (AFRS) is associated with Th2 adaptive inflammation. The purpose of this study is to show and quantify the presence of SP A, SP D, tumor necrosis factor (TNF) alpha, (a Th1 marker), and eotaxin (a Th2 marker) in normal and diseased sinus mucosa. METHODS: Intraoperative sinus mucosal biopsy specimens from human volunteers were obtained during endoscopic sinus surgery for CF (n = 4), AFRS (n = 10), and normal controls (CTLs; n = 4). Specimens were evaluated for presence and quantity of SP A, SP D, and TNF-alpha using Western blot with semiquantitative immunoblot analysis. Eotaxin was quantified using ELISA immunoassay. Results were standardized and reported as picograms of mediator per microgram of total protein. RESULTS: SP A, SP D, and TNF-alpha levels in CF tissue extracts were 2-10 times higher than levels in AFRS tissue (with SP D and TNF-alpha reaching statistical significance) but CF tissue was not significantly higher than CTL tissue. SP A, SP D, and TNF-alpha were not significantly elevated in AFRS. Eotaxin showed elevated levels in CF and AFRS when compared with CTLs (p = 0.03 and 0.003, respectively). CONCLUSION: SP D and TNF-alpha are significantly increased in CF compared with AFRS, suggesting activation of both innate immunity and Th1-mediated inflammation and potential correlation between SPs and downstream adaptive immune responses.

Rejuvenation of the aging eyelid.

Rejuvenation of the aging eyelid subunit provides a youthful appearance to one of the focal points of the face. As the age of our population increases, these procedures are likely to become increasingly more common. Accurate preoperative examination, assessment, and counseling are imperative to achieve an excellent result. As well, careful selection from the spectrum of available techniques, combined with meticulous surgical precision, will assist the surgeon in rejuvenating the individual patient. Although no one ideal surgical procedure exists, many safe and effective strategies have been developed as we have learned more about the effects of aging. This article aims to provide a history of techniques used in eyelid rejuvenation, as well as an overview of the evaluation process.