Esther Kim

Prevention and management of complications in maxillary sinus surgery.

This article is divided into six sections that are related to six commonly used operations for surgery on the maxillary sinus. The authors discuss maxillary sinoscopy, the Caldwell-Luc procedure, extended middle meatus antrostomy, endoscopic maxillary sinus antrostomy, minimally invasive sinus technique, and balloon sinus procedures. In each of these procedures, the authors discuss potential complications and address prevention and management strategies. Maxillary sinus surgery can greatly improve patients symptoms and disease process. The authors encourage the surgeon to take great care in ensuring sound surgical principles. Understanding the potential areas in which surgery can fail will help tremendously in preventing complications.

Prevention and management of skull base injury.

Skull base defects and injuries are rare, but may occur during endoscopic sinus surgery, as a result of facial trauma, or as a result of tumors in the anterior cranial fossa. Injury to the skull base can lead to catastrophic outcomes such as meningitis, brain abscess, neurological deficits, brain hemorrhage, and death. The content presents ways in which a surgeon may work to prevent or minimize injury to the skull base and describes management of skull base injuries when they do occur, reviews the current literature, and describes various reconstruction techniques used in free tissue grafts and pedicled grafts.

Takayasu arteritis: challenges in diagnosis and management

Takayasu arteritis (TA) is a rare disease affecting chiefly young women, although it can affect both men and women and persons of many different ethnicities. TA carries a high morbidity rate, but importantly, overall mortality has declined over time such that the 15-year survival rate has increased from 82.9% for patients diagnosed between 1957 and 1975 to 96.5% for those diagnosed from 1976 to 1990. Severity of presenting arterial complications and delay to diagnosis have also decreased over the past decade owing to advances in non-invasive diagnostic imaging and the development of medical therapies. Despite these advances, there still remain significant gaps in the diagnosis and management of these complex patients. These gaps encompass the basic, yet extremely complex, tasks of defining a universally accepted diagnostic criterion, accurate assessment of disease activity and development of clinically meaningful and accurate outcome measures to guide necessary clinical trials for the management of these complex patients.

Spontaneous Coronary Artery Dissection: Cardiac Manifestations of Vascular Disease

Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute coronary syndrome (ACS) in young women who otherwise do not have traditional risk factors for coronary artery disease. Though previously considered to be a rare occurrence and primarily associated with pregnancy, contemporary series have demonstrated that SCAD may account for 35% of ACS in women under the age of 50u202fyears, and peripartum SCAD accounts for the minority of cases. Importantly, an association between SCAD and arterial abnormalities in non-coronary arterial distributions has been described. The most common of these arterial abnormalities is fibromuscular dysplasia. This manuscript will briefly review the epidemiology, diagnosis, and treatment of SCAD and provide an overview of how SCAD may be a cardiac manifestation of an underlying vascular disease in the majority of patients.

Association of Multifocal Fibromuscular Dysplasia in Elderly Patients With a More Benign Clinical Phenotype: Data From the US Registry for Fibromuscular Dysplasia

Importance Fibromuscular dysplasia (FMD) is a nonatherosclerotic arterial disease that predominately affects women and is most commonly diagnosed in middle age. The natural history of FMD among patients diagnosed at an older age is not well understood. Objective To examine the differences in clinical presentation, arterial bed involvement, vascular events, and need for vascular procedures between younger and older patients with FMD. Design, Setting, and Participants Analysis of baseline data for patients enrolled in the US Registry for FMD as of December 15, 2016, at referral centers participating in the US Registry for FMD. Patients 18 years and older at the time of enrollment and those with only confirmed multifocal (string of beads type) FMD were included. Patients were categorized according to age at the time of diagnosis (≥65 years vs <65 years). Main Outcomes and Measures Prevalence of specific symptoms, vascular events, and prior vascular procedures at the time of enrollment in the registry. Results A total of 1016 patients were included in the analysis, of whom, 170 (16.7%) were 65 years or older at the time of diagnosis. Older patients with FMD were more likely to be asymptomatic at the time of diagnosis (4.2% vs 1.4%; Pu2009=u2009.02). Headache and pulsatile tinnitus, both common manifestations of FMD, were less common in older patients (40.5% vs 69.1%; Pu2009<u2009.001 and 30% vs 44.6%; Pu2009<u2009.001, respectively). Extracranial carotid arteries were more commonly involved in patients 65 years or older at time of diagnosis (87% vs 79.4%; Pu2009=u2009.03). There was no difference in prevalence of renal artery involvement, number of arterial beds involved, or diagnosis of any aneurysm. Patients 65 years or older were less likely to have had a major vascular event (37.1% vs 46.1%; Pu2009=u2009.03) and fewer had undergone a therapeutic vascular procedure (18.5% vs 33.1%; Pu2009<u2009.001). Conclusions and Relevance In the US Registry for FMD, patients 65 years or older at the time of diagnosis of multifocal FMD were more likely to be asymptomatic, had lower prevalence of major vascular events, and had undergone fewer therapeutic vascular procedures than younger patients. Patients with multifocal FMD diagnosed at an older age may have a more benign phenotype and fewer symptoms.

Non-Atherosclerotic Vascular Disease in Women

Opinion statementTakayasu arteritis, fibromuscular dysplasia (FMD), spontaneous arterial dissection, Raynaud’s phenomenon, and chilblains are vascular conditions that are associated with an increased predisposition in women and are often underdiagnosed. Takayasu arteritis has an incidence rate of 2.6 cases per million individuals per year in the USA and predominantly affects women of childbearing age. HLA-B5 genetic locus is linked with Takayasu arteritis susceptibility. Methods to determine active disease are limiting; currently utilized clinical and imaging findings and laboratory tests are of limited value for this purpose. Pregnancy poses risks for maternal and fetal complications, and these patients need additional monitoring and care before and after conception. Controlling hypertension and immunosuppression using steroids, biological and non-biological immunosuppressants, are key components of managing patients with this arteritis. FMD commonly affects middle-aged, white females. Its true prevalence is unknown. Renal and cerebrovascular beds are the most frequently involved vascular beds. Its clinical presentation varies from no symptoms to catastrophic events. Controlling vascular risk factors, periodic surveillance, and revascularization when indicated are important factors in FMD management. Spontaneous arterial dissections are less common, but are an important cause of morbidity and mortality in specific populations. Cervicocephalic dissection causes 10–20% of the strokes in young adults, and coronary artery dissection is the culprit in almost one fourth of young women presenting with acute myocardial infarction. Early diagnosis is key to improving prognosis in these patients, as the majority of patients have spontaneous resolution of the dissection with conservative management alone. Increased clinician awareness of the presentation features and angiographic findings are imperative for early diagnosis. Raynaud’s phenomenon and chilblains are cold- or stress-induced cutaneous lesions, commonly involving distal extremities. Secondary causes such as connective tissue diseases and malignancies must be thoroughly excluded during evaluation of these conditions. Cold avoidance, systemic and local warming, and oral vasodilator therapy are the mainstays of therapy.