Anne E. Getz

Complications of Primary and Revision Functional Endoscopic Sinus Surgery for Chronic Rhinosinusitis

The goal of this study was to determine the incidence of major complications following primary and revision functional endoscopic sinus surgery (FESS). In addition, this study aimed to determine factors associated with the occurrence of complications including patient and provider characteristics and the use of image guidance system (IGS) technology.

Complications following primary and revision transsphenoidal surgeries for pituitary tumors

This study aimed to determine the incidence of major complications following both primary and revision transsphenoidal pituitary surgery. Major complications included endocrinopathic, skull base, orbital, hemorrhagic and thromboembolic complications, respiratory failure, and death. Secondarily, this study aimed to examine factors associated with the occurrence of complications.

Clinical Examination of Tissue Eosinophilia in Patients with Chronic Rhinosinusitis and Nasal Polyposis

Objective (1) Describe clinical and histopathologic findings in patients with chronic rhinosinusitis with nasal polyps (CRSwNP). (2) Determine if tissue and serum eosinophilia predicts disease severity in CRSwNP. Study Design Case series with chart review. Setting Academic hospital specializing in respiratory and allergic disease. Subjects Patients with CRSwNP treated from 2008 to 2010. Methods Clinical data were collected; sinus computed tomography (CT) scans were scored according to the Lund-Mackay system; and surgical specimens were evaluated for degree of tissue eosinophilia. Statistical analysis was performed to compare eosinophilia with indicators of disease severity. Results Seventy CRSwNP patients were included, with a mean Lund-Mackay score of 16.7; 62.1% of patients had severe asthma, and 62.9% were aspirin sensitive. Elevated tissue eosinophil level did not correlate with medication usage, olfactory symptoms, or Lund-Mackay scores, nor did it correlate with presence of asthma or aspirin-sensitivity (P = .09). Patients with mild asthma had significantly more tissue eosinophils versus patients with severe asthma, possibly because of the high amount of chronic corticosteroid use in severe asthmatics. There was no correlation between tissue and serum eosinophil counts (P = .97), but there was a significant positive correlation between CT score and peripheral eosinophil level (P < .05). Conclusions Higher serum eosinophil levels may indicate more extensive mucosal disease as measured on CT scan. Neither serum nor tissue eosinophilia predicted disease severity in our retrospective analysis of CRSwNP patients, and serum eosinophil level did not serve as a marker of tissue eosinophilia.

Endoscopic Surgical Management of Vidian Nerve Schwannoma

Vidian nerve schwannomas are highly unusual, with only two reported cases in the world literature, and present with a constellation of symptoms that may be extremely vague. In the reported cases, open techniques have been utilized that required significant dismantling of the midfacial skeleton to access and manage these skull base lesions. Over the last 15 years, a paradigm shift in base of skull surgery has evolved with the advent of transnasal endoscopic techniques and instrumentation, improved surgical access and resectability of most skull‐based pathologies, including vidian nerve lesions as reported here. We describe the varied clinical presentation and radiologic findings in two patients with such rare lesions. In addition, in one of these patients, we report on the first use of an expanded endonasal technique to access and remove vidian nerve schwannomas entirely endoscopically.

Pathology quiz case 1. Glomangiopericytoma (sinonasal-type hemangiopericytoma [HPC]).

A 78-YEAR-OLD WOMAN PRESENTED WITH A 2-month history of recurrent left epistaxis. She had no history of nasal obstruction, nasal discharge, facial pressure, or headache. She had a history of hypertension, but she was otherwise healthy. Endoscopic evaluation revealed a violaceous pedunculated soft-tissue mass arising from the left posterior septum and sphenoethmoidal recess. The findings of a comprehensive head and neck examination were otherwise unremarkable. A computed tomographic scan of the sinuses revealed soft-tissue opacification of the posterior left nasal passage, without bony expansion or erosion (Figure 1). A biopsy performed at another center revealed that the soft-tissue mass was a benign lesion with features suggestive of a glomus tumor. Reportedly, the biopsy produced considerable bleeding, which required the placement of dissolvable nasal packing. The patient was subsequently referred to our institution for evaluation. The lesion was completely resected via an endoscopic approach. Pathologic analysis revealed unremarkable respiratory mucosa overlying a proliferation of spindled cells with coarse chromatin and clear to eosinophilic cytoplasm (Figure 2). Nuclear pleomorphism was mild, and neither necrosis nor mitotic activity was prevalent. There was a prominent vascular component with numerous thin-walled vessels arranged in a staghorn configuration, which was highlighted by CD34 immunohistochemical staining (Figure 3). Further immunohistochemical staining showed that the spindle cells were diffusely positive for smooth muscle actin but negative for CD34, S-100 protein, and cytokeratin. What is your diagnosis?

Basal Lamella Relaxing Incision Improves Endoscopic Middle Meatal Access

Lateralization of the middle turbinate is a commonly cited factor leading to failure of functional endoscopic sinus surgery (FESS). Inadequate medialization during FESS may require repeat intraoperative attempts, and may lead to destabilization and mucosal trauma. A novel technique is described that increases middle meatal area and provides more definitive medialization at the outset of FESS.

Landmarks for rapid localization of the sphenopalatine foramen: A radiographic morphometric analysis.

Background Transnasal endoscopic sphenopalatine artery ligation is becoming the procedure of choice for surgical management of intractable posterior epistaxis. Landmarks for localization of the sphenopalatine foramen can assist in rapid surgical exposure of the sphenopalatine artery. Objective This study examined distances from easily identified endoscopic surgical landmarks to the sphenopalatine foramen. Methods By using computed tomography of the sinus to study radiologic anatomy in 50 adults, distances were measured between five simple endoscopic landmarks and the sphenopalatine foramen. The two-tailed t-test was used for statistical analysis. Results Right- and left-sided measurements were similar. The mean (standard deviation [SD]) anteroposterior distances to the sphenopalatine foramen were the following: from the maxillary line (36.7 ± 5.5 mm), anterior head of the middle turbinate (33.8 ± 6.7 mm), basal lamella (11.8 ± 1.9 mm), and choanal arch (–9.2 ± 1.4 mm). The mean (SD) distance in the vertical dimension from the nasal floor was 26.6 ± 2.6 mm. Female patients had statistically shorter distances to the sphenopalatine foramen from the maxillary line, anterior head of the middle turbinate, choanal arch, and nasal floor. Conclusion Reliable endoscopic landmarks exist in relation to consistent anatomic structures and can be used to help quickly estimate the location of the sphenopalatine foramen at the onset of the procedure.

Endoscopic Management of Paranasal Sinus Mucoceles: Meta-analysis of Visual Outcomes:

Objective Paranasal sinus mucoceles are benign cystic lesions originating from sinus mucosa that can impinge on adjacent orbital structures, causing ophthalmic sequelae such as decreased visual acuity. Definitive treatment requires surgery. We present the first meta-analysis quantifying the effect of preoperative visual function and time to surgery on postoperative visual acuity outcomes. Data Sources PubMed, Ovid, Embase, Web of Science, and the Cochrane Library. Methods Two independent authors systematically reviewed articles describing outcomes after endoscopic sinus surgery for paranasal sinus mucoceles presenting with visual loss. Available data from case reports and series were combined to analyze the associations among preoperative visual acuity, time to surgery, and postoperative outcomes. Results Eighty-five studies were included that provided data on 207 patients. The average presenting visual acuity was 1.57 logMAR (logarithm of the minimum angle of resolution), and the average postoperative visual acuity was 0.21 logMAR, with visual improvement in 71.5% of cases. Preoperative visual acuity ≥1.52 logMAR correlated with postoperative improvement >1 logMAR (R = 0.4887, P < .0001). A correlation was found between a time to surgery <6 days and postoperative improvement (R = 0.297, P < .0001). Receiver operator curve analysis of these thresholds demonstrated a moderately accurate prognostic ability (area under the curve: 75.1 for preoperative visual acuity and 73.1 for time to surgery). Conclusion Visual loss resulting from paranasal sinus mucoceles is potentially reversible in most cases, even those presenting with poor vision. When possible, surgery should be performed promptly after diagnosis, but emergency surgery does not appear to be necessary for vision restoration.

Oral Antibiotics as Anti-infectives

Chronic rhinosinusitis is a common condition that significantly impacts the lives of many patients. The indications for antibiotic use in chronic rhinosinusitis, aside from perhaps culture-directed treatment for acute exacerbations, are ill-defined and supporting evidence for their use is sparse. Despite this, there are several important factors to consider when prescribing oral antibiotics. These are discussed herein.

Management of chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a prevalent inflammatory disorder of the paranasal mucosa, which encompasses a complex and heterogeneous disease population with variable pathophysiologic, host, and environmental etiologies. Due to this variability and an evolving understanding of its underlying etiology, successful medical and surgical management cannot be standardized and remains challenging. Medical management remains the first line strategy for this chronic condition with no known cure. Surgical therapy remains an important adjunct intervention when medical therapy fails to control the disease adequately. An up-to-date review of evidence-based recommendations, as well as emerging treatment strategies in the management of CRS follows.