Elina Matti

Paranasal sinus fungus ball: diagnosis and management.

Paranasal sinus fungus ball is an extramucosal mycosis, usually occurring in immunocompetent people as a monolateral lesion. To review the literature data and to report the Policlinico S. Matteo, University of Pavia experience, 81 patients presenting paranasal fungus ball have been treated (January 1994 to May 2005). Twenty‐seven men and 54 women (19–91 years old; mean 49.4 years) were considered. Seventy‐three patients had a single sinus affected, but eight presented multiple localisations. Maxillary was the most involved sinus followed by sphenoidal and ethmoidal. Moulds have been isolated in 28/81 cases. Histology showed fungal colonisation but not invasion in all cases. Tomography showed bone erosion in 33.3% of patients. All have been treated only by functional endoscopic sinus surgery. Seventy‐seven of 81 patients have been cured. Four of 81 patients needed another surgical treatment. Follow up was between 6 and 132 months (average: 63 months). Fungus ball is a sinusal pathology caused by mycetes like Aspergillus spp. Histology confirms the fungal aethiology excluding tissue invasion. Mycological culture consented to identify the pathogenic mould in 34.5% of cases. Actually functional endoscopic sinus surgery is the gold standard for treatment of this pathology, and antifungal therapy is unnecessary.

Removal of a Fronto‐Ethmoidal Osteoma Using the Sonopet Omni Ultrasonic Bone Curette: First Impressions

Endoscopic exeresis of sinonasal osteomas usually implicates the use of surgical drills with some disadvantages, as underlined by many authors. A new device that performs an ultrasound bone emulsification has been proposed in recent years for bone removal in various surgical disciplines. In this case report, we present the first clinical ENT experience with this device in removing a fronto‐ethmoidal osteoma, and we briefly discuss our impressions.

Adenoids during childhood: the facts.

Adenoids are constantly exposed to viral and bacterial agents as well as to allergens. They play a major role in the upper airways immunity, being effector organs in both mucosal-type and systemic-type adaptive immunity. Because of both their immunological function and their specific location, adenoids are considered to be as reservoirs of viruses and bacteria. Reiterative infections may therefore contribute both to Eustachian tube dysfunction and to tissue hypertrophy. Nasal endoscopy is a key diagnostic tool to detect both adenoid hypertrophy and adenoiditis. Moreover, such a procedure may be very helpful in detecting bacterial biofilms that could justify the concomitant presence of recurrent episodes of otitis media, chronic and occult sinusitis in children. Even though the connection between allergies and adenoidal diseases is not completely clear, allergic diseases cause an inflammatory state that influences adenoidal tissue as well, configuring the picture of allergic adenoiditis, a condition in which adenoid tissue exhibit numerous IgE positive mast cells. Several studies are still needed to better understand the relationship between allergies and infections and the influence they play on adenoids during childhood.

Hyoidthyroidpexia as a treatment in multilevel surgery for obstructive sleep apnea

Conclusion. This type of surgery is effective in patients with obstructive sleep apnea syndrome (OSAS), but may not be effective in obese patients or those with a preoperative apnea hypopnea index (AHI)>35. For these reasons, the careful study and selection of patients is fundamental in the surgical treatment of OSAS. Objectives. Evaluation of the efficacy of hyoid surgery combined with oropharynx and nose surgery in the treatment of OSAS. Subjects and methods. A total of 109 OSAS patients underwent hyoidthyroidpexia as a treatment in multilevel surgery. Before surgery all patients were treated with continuous positive airway pressure (CPAP) therapy for at least 6 months and underwent preoperative and postoperative polysomnography. The preoperative examination was composed of upper airways endoscopy, lateral cephalometric radiograph, calculation of body mass index (BMI), and subjective analysis of daytime sleepiness. Results. In all, 67/109 patients (61.5%) with postoperative AHI<20 were defined as ‘responders’, while the other 42 patients (38.5%) were defined as ‘non-responders’. The correlation between preoperative BMI and postoperative AHI revealed that non-responders had a much higher average BMI compared with responders. Moreover, when analyzing median preoperative and postoperative AHI, it emerged that non-responders had a much higher preoperative AHI compared with responders.

How we do it: A combined method of traditional curette and power-assisted endoscopic adenoidectomy

Conclusion. After conventional curette adenoidectomy, a significant mass of residual adenoid tissue is observed in about 50% of the cases. The combined approach of conventional curette and endoscopic adenoidectomy with microdebrider assures a complete and accurate removal of the mass. It is an effective and safe method without significantly prolonging the operative time. Objectives. To describe the surgical technique of conventional curette adenoidectomy completed with the microdebrider under endoscopic vision in case of residual adenoid tissue. Patients and methods. This was a retrospective review of 143 consecutive patients (age range 2–16 years, mean 6.2) who underwent endoscopic adenoidectomy for adenoid hypertrophy at an academic hospital-based institution. A classic transoral curette adenoidectomy was performed initially. Then a rigid fibre-optic endoscope was used transnasally to assess the completeness of surgery. Residual adenoid tissue was removed using a microdebrider under endoscopic vision. Results. After conventional curette adenoidectomy 70 children (48.9%) underwent residual adenoid tissue transnasal removal. Mean curette adenoidectomy time with endoscopic visualization of the nasopharynx was 9.1 min and, in the case of completion with the microdebrider, 14.6 min. No significant intraoperative bleeding, postoperative haemorrhage or other complications have occurred. After a mean follow-up of 24.4 months, no patients have been readmitted for symptoms of adenoid regrowth.

Sphenoid sinus fungus ball: our experience

Background Fungal rhinosinusitis is a common disease of the paranasal sinuses. The fungus ball (FB) is defined as an extramucosal mycotic proliferation that fills one or more paranasal sinuses. Sphenoid sinus is an uncommon localization of this disease, as reported in the literature. This study describes our experience in the diagnosis and treatment of sphenoid sinus FB (SSFB), with a particular focus on the surgical approach to the sphenoid sinus. Methods We retrospectively analyzed the clinical records of patients affected by FB of the sphenoid sinus, who underwent endoscopic sinus surgery (ESS) in our institutions between 1995 and 2009. We described the surgical technique, the methods of mycological and histopathological evaluation, as well as the perioperative and postoperative management. Results From 1995 to 2009, 226 patients affected by sinonasal FB underwent ESS in our institutions. A sphenoid localization was found in 56 patients (24.78%; mean age, 62 years). Cephalea was the most common symptom, and 14.3% of patients complained of ocular symptoms. We performed a direct paraseptal sphenoidotomy in 31 patients (55.4%) and a transethmoidal sphenoidotomy in 25 patients (44.6%). Histology unveiled fungal hyphae with absent mucosal invasion in all cases. Cultural results revealed positivity for mycotic colonization in 26 cases (46.4%, most commonly Aspergillus fumigatus). Follow-up ranged from 12 to 181 months with a mean of 70.7 months. Conclusion The description of our experience in the diagnosis and treatment of SSFB underlines the importance of a precise diagnostic pathway in case of sphenoidal disease. Nowadays, in our opinion, the paraseptal direct sphenoidotomy represents the less invasive, fastest and most anatomically conservative approach to the sphenoid sinus in case of SSFB.

Evolution in the treatment of sinonasal inverted papilloma: pedicle-oriented endoscopic surgery.

Background In the literature, the global endoscopic sinus surgery (ESS) success in the treatment of sinonasal inverted papilloma (IP) is 95%. This study was designed to describe a conservative endoscopic approach, based on research of the tumors pedicle and treatment concentrated on its site of attachment, and to compare the results of this technique with the outcome of standard endoscopic treatment. Methods Retrospective analysis of the patients treated in our institution for paranasal inverted papilloma (IP), between 2002 and 2011 with a minimum of 18 months follow-up was performed. Group A received a standard ESS including whole sinus demucosization (maxillary, ethmoid, frontal, or sphenoid sinus) and bony wall drilling. Group B patients instead underwent pedicle-oriented endoscopic surgery (POES); in this group, bony demucosization and drilling were selectively conducted around the site of pedicle attachment of the tumor. Results The cohort included 73 patients (median age, 60.5 years; median follow-up, 58 months). Group A/group B consisted of 37/36 patients. IP persistence—recurrence for group A/group B was 0/1 cases. Oncological success for global endoscopic/group A/group B was 98.6% (72/73)/100% (37/37)/97.2% (35/36). We noticed a significant difference in surgical operative time and postoperative complication rate among the groups, in favor of POES technique. Conclusion Our data confirm the efficacy of the endonasal endoscopic treatment for sinonasal IP. Moreover, the even more conservative endoscopic treatment proposed (POES) seems to offer good control of the disease, shorter operating times, avoidance of unnecessary surgery with respect to uninvolved structures, and permits a follow-up aimed at the site of the pedicle attachment.

Endoscopic evaluation of gastrointestinal tract in patients with hereditary hemorrhagic telangiectasia and correlation with their genotypes.

Purpose:Hereditary hemorrhagic telangiectasia (HHT) is an autosomal-dominant vascular dysplasia characterized by telangiectases and arteriovenous malformations. Three causative genes are known: ENG (HHT-1), ACVRL1 (HHT-2), and SMAD4 (mutated in HHT in association with juvenile polyposis). Gastrointestinal bleeding is the most common symptom after epistaxis. The stomach and the duodenum are the main gastrointestinal sites of telangiectases. Our aim was to explore gastrointestinal tract of consecutive HHT patients to assess distribution, number, size, and type of telangiectases in relation to genotype.Methods:HHT patients underwent gastroduodenoscopy, video capsule endoscopy, and colonoscopy. Molecular analysis of ENG and ACVRL1 was performed to identify the disease-causing mutation.Results:Twenty-two patients (13 men; mean age: 59 ± 9 years) were analyzed: 7 with HHT-1, 13 with HHT-2, and 2 undefined. Gastrointestinal telangiectases were identified as follows: at gastroduodenoscopy in 86% of HHT-1 patients and in 77% of HHT-2 patients, at video capsule endoscopy in all HHT-1 patients and in 84% of HHT-2 patients, and at colonoscopy in 1 patient for each group. HHT-1 showed multiple telangiectases with a higher prevalence, more relevant in the duodenum.Conclusion:Our data demonstrate extensive involvement of the gastrointestinal tract with a more severe association in HHT-1. Gastroduodenoscopy provides significant information on gastrointestinal involvement, and video capsule endoscopy may be added in selected patients. Colonic polyps/adenomas were identified as occasional findings.Genet Med 16 1, 3–10.

Resolution of invasive fungal sinusitis in immunocompromised patients: neutrophil count is crucial beside a combined medical and surgical approach.

Dear Editor, Invasive fungal sinusitis is a rare, severe infection, typically occurring in immunocompromised patients who have impaired neutrophil function or who have received longterm immunosuppressive therapy [1]. Haematological patients and among them, those affected by acute leukaemia and myelodysplastic syndrome are at higher risk [2]. The occurrence of this complication often compromises the therapeutic programme for the underlying haematological condition, necessitating a delay or cessation of chemotherapy with a subsequent high risk of relapse or progression. The acute fulminant form is characterised by its speed of evolution and is associated with a high mortality rate that reaches 100% in cases of intracranial mycotic dissemination [3]. The clinical onset is generally subtle and insidious; facial swelling or pain with or without fever must be promptly considered as possible signs of invasive sinusitis. Computed tomography (CT) evidence of pronounced thickening of the mucosa of the nasal cavity strongly suggests the diagnosis, which can be confirmed by identification of the pathogenic fungus in sinus tissues. Surgical debridement of the affected sinus is a necessary diagnostic and therapeutic procedure and must be combined with systemic antifungal therapy. The fungi most frequently involved are Aspergillus and Zygomicetes. Prognosis is related to various factors, such as the speed of diagnosis and treatment, the type of fungal infection [3], dissemination to the central nervous system, and complete neutrophil recovery [4]. The scarce information in the literature on invasive fungal sinusitis in immunocompromised patients highlights the importance and efficacy of a combined surgical and medical approach [5]. However, the factors with a major role in the evolution of the infection have not been discussed. We describe here seven cases of invasive fungal sinusitis, observed at our institution between November 2006 and December 2008, in patients affected by acute leukaemia (five patients with acute myeloid leukaemia and two with acute lymphoblastic leukaemia). These seven cases occurred among a total of 130 patients with acute leukaemia newly diagnosed in the same period. Table 1 summarises the characteristics of these seven patients and their infections. In all cases, the infection developed while the patients were severely neutropenic (neutrophil count< 500/mmc); the neutropenia was chemotherapy-related in six patients, while in one case of acute leukaemic transformation of a myelodysplastic syndrome, it was an expression of the patient’s haematological disease. This last patient had never been treated before; two out of the other six patients had received only induction chemotherapy, while the other four patients had a prior history of more chemotherapy (1–8 lines of chemotherapy). Facial pain with or without facial swelling was the initial symptom in all cases, associated with fever in six out of the seven patients. CTscanning, which P. Zappasodi (*) :M. Rossi : C. Castagnola :A. Corso : M. Bonfichi :M. Lazzarino Division of Haematology, Foundation IRCCS Policlinico San Matteo, University of Pavia, 27100 Pavia, Italy e-mail: p.zappasodi@smatteo.pv.it

Correlation of severity of epistaxis with nasal telangiectasias in hereditary hemorrhagic telangiectasia (HHT) patients.

Background Hereditary hemorrhagic telangiectasia (HHT), also known as Rendu-Osler-Weber syndrome, is an autosomal dominant disease that leads to multiregional angiodysplasia. The presence of telangiectasias in nasal mucosa leads to recurrent epistaxis that affects up to 96% of patients but with unpredictable severity. Some authors have previously explained that endonasal morphology and distribution of telangiectasias can be variable too. The purpose of this study was to evaluate any possible relationship between the severity of epistaxis and the different morphology and distribution of nasal telangiectasias in HHT patients. Methods A review was performed of nasal endoscopy records of 76 consecutive HHT patients treated for epistaxis between 2003 and 2007 at our institution. An evaluation was performed of severity of epistaxis in the same patient group using a questionnaire and considering frequency, intensity, duration of nosebleeds, and need for blood transfusions. Comparison of data collected on morphology and distribution of nasal telangiectasias with data collected on severity of epistaxis was performed. Results Morphology and distribution of nasal telangiectasias showed a statistically significant correlation with frequency and intensity of epistaxis. Presence of telangiectasias endoscopically appearing as large and prominent correlates with higher frequency of epistaxis. An increase in number of nasal subsites involved correlates with higher intensity of nosebleeds. Conclusion Our data suggest that to reduce frequency and intensity of epistaxis in HHT patients, treatments should be directed also at lesions located in the posterior part of nasal fossae and especially on telangiectasias endoscopically appearing as large and prominent.