Hironori Takebayashi

Difficulty of diagnosing Wegener's granulomatosis in the head and neck region

OBJECTIVE The objective of this study was to review the various clinical features associated with Wegeners granulomatosis (WG) in the head and neck region and to discuss the difficulty of diagnosing patients with early stage WG. METHODS Between January 1998 and August 2007, WG was diagnosed and treated in 16 patients at the Department of Otolaryngology, Hyogo College of Medicine. Clinical and operating records of these patients were analyzed retrospectively. Diagnosis was based on the Japanese criteria proposed by the Japanese Ministry of Health and Welfare in 1998. RESULTS Ten patients (62.5%) had a definite diagnosis of WG, and the other six patients (37.5%) had a probable diagnosis of WG. The period from the onset to diagnosis was between 1 month and 30 years. The generalized form of WG was observed in three patients (18.8%), and the limited form of WG was observed in the other 13 patients (81.2%). Nasal, aural, and ophthalmic symptoms were initially presented in 10, 3, and 3 patients, respectively. Cytoplasmic pattern antineutrophil cytoplasmic antibodies (cANCAs) and perinuclear pattern ANCA (pANCA) were positively detected in 68.8% (11/16) and 27.2% (3/11) of the patients, respectively. Five of 14 patients (35.7%) had pathologic features of WG in biopsy samples from the head and neck region. Three patients in whom a diagnosis of WG was difficult are presented, and immediate lessons of our experience were discussed. CONCLUSIONS This study emphasized the difficulty of diagnosing WG, particularly at an early stage and when limited to the head and neck region. The biggest challenge faced in diagnosing WG is that it requires a high index of suspicion. When WG was suspected, we should obtain an accurate medical history from patients and repeat serologic and histopathologic examinations.

Olfactory changes after endoscopic sinus surgery in patients with chronic rhinosinusitis

OBJECTIVE To address the controversy over whether olfactory function is improved or not after endoscopic sinus surgery (ESS) in patients with eosinophilic (ECRS) and non-eosinophilic chronic rhinosinusitis (non-ECRS). METHODS Between June 2006 and March 2012, 89 adult patients with CRS underwent ESS at Hyogo College of Medicine. There were 55 men and 34 women with a mean age of 53 years old, ranging from 23 to 79 years. The average follow-up period was 10.7 months (3-24) after ESS. Peripheral blood examination, sinonasal CT imaging, and four kinds of olfaction tests [self-administered olfaction test (SAOQ), visual analog scale (VAS), T&T recognition threshold tests (T&T) and intravenous olfaction test using prosultiamine] were performed. We diagnosed ECRS when (i) symptoms of nasal congestion and olfactory disorder, (ii) bilateral chronic rhinosinusitis with nasal polyps (CRSwNPs), (iii) peripheral blood eosinophilia (>7.0%), and (iv) ethmoid sinus dominant opacification in preoperative CT findings (i.e. ethmoid sinuses (E) were more bilaterally occupied than those of maxillary sinuses (M), E/M≥1), were completely fulfilled. We divided the patients into two groups of ECRS (group A) and non-ECRS (group B). Olfaction tests before operation, and at the 3rd, 6th, 12th, and 24th month postoperation were analyzed. The severity and therapeutic evaluation of olfaction were based on criteria of T&T recognition thresholds. RESULTS The mean SAOQ and VAS scores showed significant improvement within 6 months after ESS in both group A and group B. In total, the improvement rates were 52.0% (26/50) at 3 months, 58.5% (24/41) at 6 months, 40.5% (15/37) at 12 months, and 41.2% (7/17) at 24 months. The significant improvement of T&T recognition thresholds in group B was maintained for 24 months, whereas those in group A, showing transient improvement, deteriorated after 12 months or more. A significant difference in postoperative T&T recognition between groups A and B was found at the 12th postoperative month. In both A and B, 84% of patients had a response to prosultiamine (positive group) in the preoperative stage. T&T thresholds in the positive group were significantly better that those in the negative groups in the postoperative stage. CONCLUSION Olfactory disorders due to ECRS showed transient improvement that deteriorated as time passed after surgery. The olfaction in the non-ECRS patients recovered comparatively well. Postoperative olfactory results were unfavorable in patients without a preoperative reaction to prosultiamine.

Novel endoscopic scoring system after sinus surgery.

OBJECTIVE To propose a simple post-operative endoscopic scoring system for use after endoscopic sinus surgery (ESS) in patients with chronic rhinosinusitis (CRS), and to demonstrate the usefulness of this approach. METHODS Subjects comprised 116 patients (84 men, 32 women; mean age, 54 years) with CRS who were analyzed endoscopically and radiologically after ESS between 2006 and 2012. The study was designed as a case series with planned data collection in the setting of university medical centers. Patients were followed-up for ≥ 6 months after ESS (mean, 13.1 months). Both pre- and post-operative computed tomography (CT) findings of each sinus and olfactory cleft (OC) were scored according to the Lund-Mackay scoring system: 0, normal; 1, partially; or 2, completely occupied. CT score represents the total score expressed as a percentage of the maximum possible score (12 points per side). Post-operative endoscopic score (E score, %) was calculated as the maximum score according to physical findings on each operated sinus and OC: 0, normal; 1, partially diseased; or 2, completely closed. Post-operative course using E score was verified by comparison with the Lund-Kennedy (L-K) scoring system. RESULTS E score was easily and quickly determined. Interclass correlation coefficient among 10 otolaryngologists indicated high-level inter-rater reliability (0.922). E score correlated strongly with both CT score (n=116, p<0.0001, rs=0.755) and L-K score (n=79, p<0.0001, rs=0.723). CONCLUSION Endoscopic evaluation using E score for sinuses and OCs after ESS is a useful method, together with L-K score for the nasal cavity and radiological study.

Therapeutic Evaluation of Outpatient Submucosal Inferior Turbinate Surgery for Patients with Severe Allergic Rhinitis

BACKGROUND Surgical treatment for inferior turbinate (IT) is selected to treat severe allergic rhinitis (AR) that is unresponsive to conservative treatment. This study aimed to determine the clinical effects of outpatient submucosal IT surgery (OSITS) on patients with severe AR. METHODS Between January 2008 and August 2012, 95 patients with severe AR who underwent OSITS at the Department of Otolaryngology, Hyogo College of Medicine, were retrospectively analyzed. There were 53 men and 42 women. Their mean age was 27 years (11-75 years). OSITS was bilaterally performed using a bipolar radiofrequency electrocautery under local anesthesia. Symptoms, QOL, and physical findings were evaluated using scores from both pre- and postoperative periods (average: 12.4 months), according to Practical Guideline for the Management of AR in Japan 2009. RESULTS In perennial AR, all mean scores of nasal symptoms, QOL, and physical findings significantly improved after OSITS (p < 0.05, n = 83). Nasal obstruction, sleep problems, and IT congestion were the most strongly affected. Eye symptoms were not influenced by OSITS. OSITS also showed significant effects on nasal obstruction and IT congestion in seasonal AR (p < 0.05, n = 12), but not sneezing, nasal discharge, and QOL. In terms of the efficacy, OSITS was beneficial in 90% of perennial AR cases and 75% of seasonal AR cases. Epistaxis (1%), vestibulitis (1%), and IT atrophy (4%) were observed after OSITS. CONCLUSIONS These data indicate that OSITS using radiofrequency electrocautery could be a beneficial therapeutic option in patients with severe AR.

Clinical Features of Patients Treated with Endoscopic Sinus Surgery for Posttraumatic Paranasal Sinus Mucocele

Aim: The purpose of this study was to analyze the clinical features of patients with posttraumatic paranasal sinus mucocele (PSM). Subjects and Methods: Between 2009 and 2013, we performed endoscopic sinus surgery (ESS) on 68 patients with PSM at the Department of Otolaryngology - Head and Neck Surgery at Hyogo College of Medicine. Five male patients (age range, 45-76 years) with posttraumatic PSM were analyzed retrospectively. Diagnosis was based on the history of injury and radiological findings. Results: Posttraumatic PSM was found in 7% (5/68) of patients. The mean interval from injury to diagnosis was 28.4 years. All patients had frontal sinus mucocele. Four patients had symptoms of headache, diplopia, visual field defect, and forehead swelling, and 1 patient was asymptomatic. ESS was performed under general anesthesia in all cases, and the symptoms improved postoperatively. Reoperation was required in 1 patient (20%) because headache developed with obstruction of the frontal drainage route 7 months after ESS. Conclusions: Posttraumatic PSM was the least frequent form of PSM and was located predominantly in the frontal sinus, causing symptoms long after the forehead injury. The important lessons to be learned for treating posttraumatic PSM are to obtain a detailed history and to enlarge the route to the cyst to avoid its recurrence.

Clinical Study of 1,515 Patients Presenting with Epistaxis Over the Last 6 Years

Aim: This study reviews our clinical experience of patients with epistaxis and discusses proper management. Patients and Methods: We retrospectively investigated 1,515 patients with epistaxis treated in our department between 2005 and 2010. Results: Men over 50 years old predominated. More than half of the patients (n = 828) first visited after consultation hours, and 40% (n = 606) were brought by ambulance. The most common underlying diseases were circulatory diseases (69%, n = 1,047). Antithrombotics were being administered to 23% (n = 345). Kiesselbachs plexus was the most commonly observed bleeding site (51%, n = 769). In 20% (n = 297), no bleeding point was confirmed because hemostasis had been achieved on arrival. Anterior packing was the most common primary treatment, followed by electrocauterization. Hospitalization was required in 2% (n = 30). Re-bleeding occurred within 14 days after primary treatment in 14% (n = 206). Surgical treatment was performed for 5% (n = 11). Conclusions: Patients showing repeated pulsatile arterial bleeding require hospitalization for surgical therapy, although outpatient therapy is sufficient in most cases. A risk of re-bleeding should be considered if patients show unclarified bleeding points and circulatory diseases.

Inferior Turbinate Surgery for Severe Allergic Rhinitis

Objective: Inferior turbinate surgery, an outpatient surgery, is used to treat severe allergic rhinitis that is unresponsive to medication. The purpose of this study was to determine the clinical effects of outpatient inferior turbinate surgery (OITS) on patients with severe allergic rhinitis. Method: Between January 2008 and December 2011, we performed OITS bilaterally under local anesthesia for 216 patients with severe allergic rhinitis. Two kinds of cautery device, high-frequency electrocautery and argon plasma coagulation, were used. Nasal symptoms and intranasal findings were evaluated pre- and postoperatively at 3 months or more after OITS. Results: On average, scores for sneezing, nasal discharge, and nasal obstruction significantly improved from 1.3 to 0.8, from 1.7 to 1.1, and from 2.6 to 1.2 (P < .001, n = 216), respectively. Overall, improvement of symptoms was found in 73% (157/216 patients) postoperatively. Congestion of inferior turbinates also improved in 74% (160/216 patients). Conclusion: These data indicate that the OITS had an effect on more than 70% of patients with severe allergic rhinitis.

Clinical Study of 1304 Patients with Epistaxis for Recent 5 Years

Objective: Epistaxis is one of the most common symptoms encountered in the ENT clinic. In this study, we reviewed our recent clinical experience of patients with epistaxis and discussed important lessons for the management of cases of epistaxis. Method: Between 2005 and 2009, 1304 patients with epistaxis were treated at our department. There were 795 men and 509 women. Mean age was 57 years (range, 0-99 years). Clinical features: situations at the first visit; pathogenesis; bleeding points; methods of treatments; and clinical courses were retrospectively investigated. Results: The 700 patients (54%) first visited in the nighttime. The most common condition was hypertension in 388 patients (30%) followed by cardiovascular disease in 262 patients (20%). The 630 patients (48%) were on medication with hypotensors and/or antithrombotic drugs. Kiesselbach’s plexus was the mostly observed, as it was observed in 679 patients (52%). In 225 patients (17%), bleeding point was not confirmed. The 424 patients (33%) were primarily treated by anterior packing, followed by electrocauterization in 365 patients (28%). Re-bleedings within 14 days after the primary treatments were found in 181 patients (14%). Hospitalized surgical treatments were required in 3% (6/181 patients). Conclusion: Outpatient therapy is usually enough to arrest hemorrhage in major cases. However, we have encountered patients with repeating arterial pulsing bleedings who require emergent hospitalized surgical therapy. Risk of re-bleeding within a day should be considered if patients had uncertain bleeding point and circulatory diseases.

S276 – Nasal Sinus Diseases Demonstrating Ophthalmologic Symptoms

Objectives This study reviewed the clinical features of paranasal sinus diseases demonstrating ophthalmologic manifestations. Methods Between April 1995 and December 2007, we performed endoscopic sinus surgery (ESS) in 106 patients with paranasal sinus diseases presenting with ophthalmologic symptoms. There were 57 men and 49 women, aged 56.4 years (10 − 86 years). Diagnosis was based on the pre- and intraoperative findings. Patients with symptoms due to tumors were excluded from this study. Results Of 106 patients, loss of visual acuity was most frequently observed in 40 patients (37.7%). Other symptoms were eyelid swelling (28.3%), diplopia (18.9%), constriction of the visual field (13.2%), exophthalmos (13.2%), ocular pain (12.3%), external ophthalmoplegia (3.8%), and epiphora (1.9%). The symptoms involved in paranasal sinus cysts were found in 67 patients (63.2%), those in bacterial sinusitis in 36 patients (34.0%), those in fungal sinusitis in 2 patients, and those in Wegeners granulomatosis in 1 patient. The 38 patients (35.8%) were diagnosed as rhinogenic optic neuropathy, and most of them (32/38 patients, 78.9%) initially referred to ophthalmologists. Major lesions were observed in anterior and posterior ethmoid sinus (40 patients, 37.7%). For the treatment, external approaches were required in 11 patients (10.4%). During the postoperative course, reoperation (ESS) was required in 3 patients (2.8%) because of recurrence in the sphenoid sinus, whereas the other 103 patients had an uneventful course. Conclusions Pre- and postoperative observation by not only otolaryngologists, but also ophthalmologists, is recommended in order to perform minimally invasive surgery and to avoid recurrence.