Ismail Elnashar

Frontal sinus fractures with suspected outflow tract obstruction: A new approach for sinus preservation

OBJECTIVE The description of a new approach for the management of patients with frontal sinus fractures and associated obstruction of the frontal outflow tract to, restore sinus function and avoiding sinus obliteration. SUBJECTS AND METHODS In a prospective study, 21 patients with anterior wall frontal sinus fractures associated with potential obstruction of the frontal outflow tract, underwent rigid internal fixation and intraoperative guarded nasal endoscopic debridement of any bony spicules and lacerated mucosa to clear the frontal recess. Patients were followed up clinically and radiologically by CT to assess the status of the frontal sinus and to detect any manifestations of frontal sinusitis or any other complications. RESULTS Seventeen patients completed the postoperative follow-up while four patients were excluded from the study. Postoperative follow-up ranged from 6 to 34 months with a mean of 20 months. All patients had associated craniofacial fractures. Follow-up CT scans showed complete restoration of frontal sinus ventilation and mucociliary clearance for 13 patients. Four patients showed frontal sinus mild mucosal thickening without signs of chronic sinusitis. CONCLUSION Patients with anterior wall frontal sinus fractures associated with frontal sinus outflow tract obstruction could be successfully managed with rigid internal fixation and intraoperative guarded endoscopic debridement of any bony spicules and lacerated mucosa to clear the frontal recess. This type of management could increase the chance of frontal sinus preservation and decrease the need for frontal sinus obliteration for similar patients.

Voice Outcome after Gore-Tex Medialization Thyroplasty

Introduction Although medialization thyroplasty utilizing Gore-Tex (Gore and Associates, Newark, Delaware, United States) has been discussed in the literature, few reports have assessed voice quality afterward, and they did not use a full assessment protocol. Objective To assess the improvement in voice quality after medialization thyroplasty utilizing Gore-Tex in patients with glottic insufficiency of variable etiology. Methods Eleven patients with glottic insufficiency of different etiologies that failed compensation were operated by type 1 thyroplasty utilizing Gore-Tex. Pre- and postoperative (1 week, 3 months, and 6 months) voice assessment was done and statistical analysis was performed on the results. Results In all postoperative assessments, there was significant improvement in the grade of dysphonia (p < 0.004) and highly significant reduction in the size of glottic gap and prolongation of maximum phonation time (p < 0.0001). The difference in voice parameters in the early (1 week) and the late (3 and 6 months) postoperative period was not significant. None of the patients developed stridor or shortness of breath necessitating tracheotomy, and there was no implant extrusion in any patient during the study period. Conclusion Gore-Tex medialization provides reliable results for both subjective and objective voice parameters. It leads to a satisfactory restoration of voice whatever the etiology of glottic incompetence is. This technique is relatively easy and does not lead to major complications. Further studies with larger number of patients and more extended periods of follow-up are still required to assess the long-term results of the technique regarding voice quality and implant extrusion.

Objective assessment of endoscopy assisted adenoidectomy

OBJECTIVES To objectively assess the effectiveness of endoscopy assisted adenoidectomy utilizing adenoid tissue volume measurement and to set some parameters for which patients are more legible to this procedure. METHODS Forty three patients for whom adenoidectomy was conventionally done using adenoid curettes. Surgeons satisfaction for adenoid removal after curettage and digital palpation was reported. The volume of removed adenoidal tissue was measured. The remaining adenoid tissue, if any, was removed transnasally guided by endoscope. Residual adenoid volume was also was measured. The data was tabulated and statistically analyzed. RESULTS The volume of adenoid removed by curettage ranged from 1 to 3.6 ml with a mean of 2.45 ml. The volume of residual adenoid removed by endoscopy after curettage ranged from 0 to 2.9 ml (mean: 0.67 ± 0.58 ml). The volume of residual adenoid after blind curettage was found to have statistically significant relation to older age of patients, preoperative larger adenoid by X-ray and Surgeons dissatisfaction about the completeness of removal after curettage. CONCLUSION Conventional curettage adenoidectomy misses a substantial volume of adenoid tissue. Endoscopy-assisted adenoidectomy is significantly recommended in children age  >10 years, dissatisfied surgeon after curettage and palpation, and grade 3 adenoid enlargement on X-ray.

5 years follow up after transnasal endoscopic surgery of Thornwaldt's cyst with powered instrumentation

OBJECTIVE To assess the long term results of a transnasal endoscopic, power-assisted marsupilization of Thornwaldts cyst (TC). METHODS Patients who were operated and followed up at our institution for the management of symptomatic TC in the period from February 2002 till May 2012 were included in the study. All the patients were operated through a transnasal endoscopic power-assisted marsupilization of the cyst. RESULTS Eleven patients with a diagnosis of TC (by nasaoendoscopy, CT and MRI) were included in this study. They included six males and five females with age ranging from 15 to 55 years. Transnasal endoscopic, power-assisted marsupilization was performed for all cases with no intra- or postoperative complications. Throughout 5 years follow up, no recurrence of the cyst or its related symptoms were reported. CONCLUSION Long term (5 years) follow up showed that transnasal endoscopic marsupilization of Thornwaldts cyst using micodebrider is a safe and effective maneuver with no cyst recurrence, eustachian tube affection or post-operative complications.

Computed Tomography Measurement of Inferior Turbinate in Asymptomatic Adult

Introduction  The inferior turbinate (IT) is the most susceptible turbinate to enlargement causing nasal obstruction. The common belief ascribes most of the enlargement of the IT to mucosal elements. Objective  This study aimed to investigate the detailed computed tomography (CT) measurement of the IT in asymptomatic adult by determining the thickness of both the non-bony (mucosa) and bony parts and their relation to nasal air space in different related areas of the nose. Methods  We included in the study paranasal CT scans of 108 individuals (216 IT) that had no paranasal pathology. We acquired axial images with multiplanar reformates to obtain delicate details in coronal and sagittal planes for all subjects. We took separate measurements of the thickness of the medial mucosa, bones, and lateral mucosa of the IT on the anterior and posterior portions of ITs. We also measured the air space of the nasal cavity between the septum and IT anteriorly and posteriorly. Results  The difference in the air space between nasal septum, anterior and posterior ends of IT was extremely statistically significant (P < 0.0001). The thickness of the medial mucosa was extremely significantly more than the lateral mucosa width (P < 0.0001). There was no significant difference in length of IT at both sides ( p  = 0.5781). Conclusion  The detailed CT measurement of the IT in normal adult is an easy and novel measurement. This study lays the foundation for CT measurement of IT for further work that can describe changes in IT measures after turbinate surgery.

Ipsilateral Reduced Olfactory Bulb Volume in Patients with Unilateral Nasal Obstruction

Objectives To evaluate the effect of unilateral nasal obstruction (by nasal polyps of different histopathology) on olfactory bulb volume using MRI technique. Study Design Cross-sectional study. Setting Tertiary university hospitals, Departments of Otolaryngology and Radiology. Subjects and Methods Eleven patients with a few months of complete unilateral nasal obstruction of different pathological etiologies were selected. MRI assessment of olfactory bulb volume was performed using planimetric manual contouring. The contralateral olfactory bulb was used as a comparative control for the same patient. Eleven healthy controls constituted the control group. Results Mean olfactory bulb volume ±SD of obstructed side = 14.3 ± 3.7 mm3, mean olfactory bulb volume ±SD of nonobstructed side = 43.49 ± 10.7 mm3. The difference between the 2 sides was significant (P = .003). The difference in olfactory bulb volume between normal subjects and nonobstructed nasal side was statistically nonsignificant (t = .9118, P = .3727), while the difference between normal subjects’ olfactory bulb volume and obstructed nasal side olfactory bulb volume in our patients was extremely statistically significant (t = 9.7320, P < .0001). A strong negative correlation was found between duration of obstruction and olfactory bulb volume (R = −0.9761). Conclusion This study shows that unilateral nasal obstruction may be associated with a lateralized ipsilateral difference of olfactory bulb volume.

Effect of central inset pharyngeal flap for velopharyngeal insufficiency on eustachian tube function.

The aim of this study was to assess the effect of the central inset pharyngeal flap, used for correcting persistent velopharyngeal incompetence after cleft palate repair, on Eustachian tube (ET) function.

Normal Nasopharyngeal Measurement by Computed Tomography in Adult

Background: This study aims to investigate the detailed computed tomography (CT) measurement of the nasopharynx (NP) in normal adult detecting mean of its dimension and relation of that measurement to that of the sphenoid sinus. Methodology/Principal: A normal paranasal CT scan and a straight nasal septum of 128 individuals (256 sphenoid sinuses) were included in the study. Axial images were acquired with multiplanar reformates to obtain delicate details in coronal and sagittal planes for all subjects. Measurement of the width, length, and anteroposterior dimensions of the NP and sphenoid sinuses were taken separately. Results: In 128 studied CT of adult subjects, the mean height of the NP was 19.4619 ± 4.52661 and mean depth was 21.80714 ± 4.62324 while the mean width was 25.31951 ± 3.80521. No significant relations between diameters of NP and sphenoid sinuses were found. Conclusion: The detailed CT measurement of the NP in normal adult is an easy and reliable measurement. This study put the base of CT measurement of NP for further work to describe changes in such measures in patients with nasal and paranasal sinus anomalies.

Oropharyngeal packing for resistant post-tonsillectomy bleeding

Background Tonsillectomy remains a common surgical procedure with a substantial risk for complications, the greatest of which is postoperative hemorrhage. Objective The aim of this study was to assess the efficiency of oropharyngeal packing around the orotracheal tube to control resistant, potentially lethal, post-tonsillectomy bleeding. Patients and methods Six patients were presented to our institution with massive (potentially fatal) post-tonsillectomy hemorrhage from January 2002 to June 2011. After failure of initial measures to control bleeding, oropharyngeal packing around the orotracheal tube with or without a nasogastric tube was inserted to compress the bleeding areas. Results Oropharyngeal packing succeeded in controlling and stopping resistant post-tonsillectomy bleeding in all cases. Conclusion Resistant, potentially fatal, post-tonsillectomy bleeding could be controlled by oropharyngeal packing around orotracheal tubes, and this can be tried first before external carotid artery ligature.

Insulin-like growth factor alpha changes after tonsillectomy for obstructive and nonobstructive causes

Abstract To assess the effect of tonsillectomy, weather performed for obstructive or nonobstructive causes, on the serum levels of insulin-like growth factor alpha (IGF-1). This prospective study was carried out on 60 children who underwent tonsillectomy or adenotonsillectomy at Zagazig University Hospitals. The children were divided into two groups: the first group included 30 children who underwent tonsillectomy because of obstructive symptoms and the second group included 30 children who underwent tonsillectomy because of recurrent tonsillitis with no manifestations of upper-airway obstruction. Preoperative and 3 months’ postoperative blood levels of IGF-1 were estimated and the data were statistically analyzed. Six children from the first group (24 children) and four children from the second group (26 children) did not follow-up after surgery and were excluded from the study. Both study groups were matched for age and sex. In the first (obstructive) group, there was a statistically significant increase in the mean level of IGF-1 from 119.08109 ± 27.81797 preoperatively to 222.395 ± 6.62559 postoperatively and the difference was significant (P < 0.0001). However, in the second (infection) group, the mean IGF-1 values increased from 155.0715 ± 89.83015 preoperatively to 191.4075 ± 57.38667 postoperatively, and the difference was not significant (P = 0.0883). Insufficient weight and height gain in children who had obstructive adenotonsillar hypertrophy could be attributed to low IGF-1, and this can be corrected after surgery. This is not the case in patients with chronic tonsillitis without upper-airway obstruction, and other factors may explain the retarded growth in these patients. Study design A prospective study.