Hesham Saleh

Outcome of Endoscopic Sphenopalatine Artery Occlusion for Intractable Epistaxis: A 10‐Year Experience

Objective/Hypothesis: To evaluate the efficacy of surgical sphenopalatine artery occlusion (SAO) for treating intractable epistaxis, and identify factors associated with long‐term success or failure of this procedure.

Neuronal Markers in Allergic Rhinitis: Expression and Correlation With Sensory Testing

Introduction: Although the role of immunoglobulin E‐mediated hypersensitivity reactions in allergic rhinitis is well known, the relative contribution of sensory nerves to the symptoms of rhinitis is uncertain. This study looked at the level of specific neuronal markers including the nerve marker protein gene product 9.5 (PGP 9.5), sensory and autonomic neuropeptides, the capsaicin/heat receptor TRPV1, and nerve growth factor (NGF) in patients with allergic rhinitis and controls and their correlation with nasal sensitivity.

The menthol and cold sensation receptor TRPM8 in normal human nasal mucosa and rhinitis.

BACKGROUND Menthol and cold sensation trigger symptoms and reflex responses in the upper airway, but the underlying molecular mechanisms are unknown. We have therefore studied nerve fibres expressing the menthol and cold receptor TRPM8 in normal human mucosa, and in rhinitis. TRPM8 nerve fibres were compared with those expressing other TRP receptors including TRPV1 (capsaicin and heat receptor), and TRPA1 (mechano-cold receptor). METHODS Immunohistology and image-analysis were used to study TRP receptors in biopsies of nasal turbinate from control subjects, patients with allergic rhinitis, and non-allergic rhinitis. RESULTS TRPM8-immunoreactive nerve fibres were observed in the sub-epithelium, and were profuse around blood vessels in deeper regions, where they were markedly greater in number than TRPV1+ fibers. Image analysis of TRPM8 in sub-epithelial and vascular regions showed no significant differences between control and the rhinitis patient groups. TRPA1-immunoreactivity was weak and seen rarely in nerve fibres. CONCLUSION We show that TRPM8 nerve fibres are abundant in nasal mucosa particularly around blood vessels, and may mediate neurovascular reflexes. TRPM8 antagonists deserve consideration for therapeutic trial in rhinitis.

Endonasal endoscopic approach to the petrous apex: an image-guided quantitative anatomical study.

Background:  The petrous apex is a relatively inaccessible region, deeply situated within the skull base. Removal of lesions from this area, traditionally accomplished via lateral approaches, can cause significant morbidity. We undertook an anatomical study to investigate the surgical anatomy of the petrous apex through an endonasal endoscopic approach, which has been sporadically described in the literature, to investigate its feasibility and to characterise clear and consistent surgical landmarks for access.

Image-guided, endoscopic removal of migrated titanium dental implants from maxillary sinus: two cases.

OBJECTIVE We present two cases of dental implant migration into the maxillary sinus, with subsequent removal via image-guided, transnasal endoscopy. METHOD Presentation of clinical cases, together with a literature review of alternative surgical techniques, the theories behind implant migration, and the benefits of an image-guided, endoscopic approach. RESULTS One patient was asymptomatic, and the other had begun to experience sinogenic symptoms after implant displacement. Both patients presented to the ENT clinic, and both underwent the BrainLab protocol to generate computed tomography images for navigational reconstruction. Transnasal endoscopy was carried out with this guidance, and the implants were removed successfully in both cases. Previously used surgical techniques such as the Caldwell-Luc procedure or extraction through the tooth socket have higher rates of conversion to open procedures, more damage to the nasal sinuses and higher post-operative complication rates compared with the transnasal endoscopic approach. CONCLUSION Both patients underwent successful removal of their migrated dental implants with no complications, and neither required any follow-up intervention.

Increased nerve fiber expression of sensory sodium channels Nav1.7, Nav1.8, And Nav1.9 in rhinitis.

Introduction: Voltage‐gated sodium channels Nav1.7, Nav1.8, and Nav1.9 are involved in nerve action potentials and have been proposed to underlie neuronal hypersensitivity. We have therefore studied their levels in allergic and nonallergic rhinitis.

Versatile applications of the polydioxanone plate in rhinoplasty and septal surgery.

BACKGROUND Rhinoplasty and septal surgery often require the use of cartilage grafts. Autologous cartilage may be thin or deviated, and the use of an absorbable scaffold material to support the reimplanted cartilage during healing can improve technique and outcomes. OBJECTIVE To describe the use of a polydioxanone plate not only as a template in extracorporeal septoplasty but also for various other grafts commonly used in rhinoplasty and for the repair of septal perforations. METHODS A retrospective case note review was performed between November 1, 2007, and February 28, 2011, for all patients treated using a polydioxanone plate. Surgical outcomes are discussed. RESULTS A polydioxanone plate was used in septal and/or rhinoplasty surgery in 102 patients treated during a 40-month period. Follow-up was 9 to 18 months (mean, 12 months), with 96 patients reporting a good cosmetic or functional result. Up to 15% of patients experienced temporary septal swelling, but there were only 2 postoperative infections and no other significant complications. CONCLUSIONS The polydioxanone plate is a safe and reliable absorbable implant that has many different applications in rhinoplasty and septal surgery. It not only acts as a scaffold but also stimulates and guides cartilage regeneration.

Impact of Rhinoplasty on Objective Measurement and Psychophysical Appreciation of Facial Symmetry

OBJECTIVES To determine the impact of rhinoplasty on the objective measurement and subjective appreciation of facial symmetry and to investigate whether perceptual shifts are correlated with objective changes in facial proportions. DESIGN Frontal view photographs were used to measure bilateral symmetry ratios of the medial and lateral canthi, tragus, ala, and oral commissure in 100 patients before and 6 months after rhinoplasty. Gestalt dichotomous impressions of facial symmetry were also obtained in all cases. Paired t tests and chi(2) tests were used to compare facial proportions and the proportion of faces perceived as symmetrical, respectively, before and after surgery. The receiver operating characteristic and analysis of variance were used to assess whether perceptual shifts in symmetry could be correlated with objectively measurable changes in facial proportion. RESULTS The number of faces perceived as symmetrical increased from 42 to 62 after rhinoplasty (P < .001, chi(2) test). Objectively, midline-to-ala symmetry increased from an average of 91.1% (5.5%) (mean [SD]) to 93.8% (4.5%) after rhinoplasty (P < .001, paired t test). Other facial proportions did not change significantly (P > .10). The degree of change in midline-to-ala symmetry was the only objective measure that was significantly associated with the subjective perception of the face as symmetrical or asymmetrical (P < .01, 1-way analysis of variance). Most positive perceptual shifts were associated with an objective improvement in nasal symmetry that was greater than 2%. Conversely, most negative perceptual shifts were associated with minimal postoperative improvement or loss of nasal symmetry. CONCLUSION Rhinoplasty leads to objectively measurable changes in nasal symmetry that correspond with psychophysical modifications in the perception of a face as symmetrical or asymmetrical.

Pseudomeningoceles of the sphenoid sinus masquerading as sinus pathology

To describe the clinical presentation, pathophysiology, and treatment of spontaneous cerebrospinal fluid (CSF) leaks of the sphenoid bone, with an emphasis on a previously undescribed form in this location, in which CSF is trapped under the mucosa of the sinonasal cavity or in the soft tissue of the skull base.

Balloon Sinuplasty™: balloon-catheter dilation of paranasal sinus ostia for chronic rhinosinusitis

More than 100 million patients worldwide suffer from chronic rhinosinusitis, and a considerable amount of money has been spent on research and treatments by healthcare providers. In the northern hemisphere, damp, temperate climates, along with higher concentrations of pollen, are associated with a higher prevalence of chronic rhinosinusitis. Owing to its persistent nature, the disease can become a significant cause of morbidity. If untreated, it can reduce quality of life and productivity. When medical treatment is not effective, surgery may offer an excellent outcome. Although functional endoscopic surgery has proven to be effective, many cases could be managed medically. Recent research has suggested that optimal medical treatment is as effective as surgery in patients with chronic rhinosinusitis at the end of 1 year. Balloon Sinuplasty™ (Acclarent, Inc., CA, USA) is a new technique in the management of sinusitis and is a hotly debated topic. It is a delicate, minimally invasive tool, and early research demonstrates promising outcomes in terms of safety and effectiveness. This novel technique has been approved by the US FDA. Recently, NICE raised no concerns regarding its safety and efficacy but will continue to review this procedure.