Jivianne T. Lee

Microvascular flap reconstruction of the mandible: A comparison of bone grafts and bridging plates for restoration of mandibular continuity

OBJECTIVE To compare the efficacy of vascularized bone grafts and bridging mandibular reconstruction plates for restoration of mandibular continuity in patients who undergo free flap reconstruction after segmental mandibulectomy. Study design and setting A total of 210 patients underwent microvascular flap reconstruction after segmental mandibulectomy. The rate of successful restoration of mandibular continuity in 151 patients with vascularized bone grafts was compared to 59 patients with soft tissue free flaps combined with bridging plates. RESULTS Mandibular continuity was restored successfully for the duration of the follow-up period in 94% of patients who received bone grafts compared with 92% of patients with bridging mandibular reconstruction plates. This difference was not statistically significant. In patients who received bone grafts, most cases of reconstructive failure occurred during the perioperative period and were due to patient death or free flap thrombosis. In patients who received bridging plates, all instances of reconstructive failure were delayed for several months and were due to hardware extrusion or plate fracture. CONCLUSIONS Vascularized bone-containing free flaps are preferred for reconstruction of most segmental mandibulectomy defects in patients undergoing microvascular flap reconstruction. However, use of a soft tissue flap with a bridging mandibular reconstruction plate is a reasonable alternative in patients with lateral oromandibular defects when the nature of the defect favors use of a soft tissue free flap. SIGNIFICANCE Both bone grafts and bridging plates represent effective methods of restoring mandibular continuity following segmental mandibulectomy, with the former being the preferred technique for patients undergoing microvascular reconstruction.

Clinical Consensus Statement: Pediatric Chronic Rhinosinusitis

Objective To develop a clinical consensus statement on the optimal diagnosis and management of pediatric chronic rhinosinusitis (PCRS). Methods A representative 9-member panel of otolaryngologists with no relevant conflicts of interest was assembled to consider opportunities to optimize the diagnosis and management of PCRS. A working definition of PCRS and the scope of pertinent otolaryngologic practice were first established. Patients of ages 6 months to 18 years without craniofacial syndromes or immunodeficiency were defined as the targeted population of interest. A modified Delphi method was then used to distill expert opinion into clinical statements that met a standardized definition of consensus. Results After 2 iterative Delphi method surveys, 22 statements met the standardized definition of consensus while 12 statements did not. Four statements were omitted due to redundancy. The clinical statements were grouped into 4 categories for presentation and discussion: (1) definition and diagnosis of PCRS, (2) medical treatment of PCRS, (3) adenoiditis/adenoidectomy, and (4) endoscopic sinus surgery (ESS)/turbinoplasty. Conclusion Expert panel consensus may provide helpful information for the otolaryngologist in the diagnosis and management of PCRS in uncomplicated pediatric patients.

Isolated Inverting Papilloma of the Sphenoid Sinus

Objectives/Hypothesis Primary inverting papilloma of the sphenoid sinus is rare. We present a case of inverting papilloma with isolated involvement of the sphenoid sinus and discuss the incidence, clinical presentation, radiographic features, histological findings, and management of patients with this disease.

Antimicrobial lipids: novel innate defense molecules are elevated in sinus secretions of patients with chronic rhinosinusitis.

Background Airway secretions possess intrinsic antimicrobial properties that contribute to the innate host defense of the respiratory tract. These microbicidal capabilities have largely been attributed to the presence of antibacterial polypeptides. However, recent investigation has indicated that host-derived lipids including cholesteryl esters also exhibit antimicrobial properties. The purpose of this study was to determine whether sinus secretions contain such antimicrobial lipids and to compare the lipid composition in patients with and without chronic rhinosinusitis (CRS). Methods Maxillary sinus fluid was obtained via antral lavage from subjects with (seven patients) and without (nine patients) a history of CRS. After specimen collection, total lipid was extracted according to Bligh and Dyer (Bligh EG and Dyer WJ, A rapid method of total lipid extraction and purification, Can J Biochem Physiol 37:911–918, 1959) and lipid profiles were obtained by reverse phase high-performance liquid chromatography on an amide-embedded C18 column. In addition, the neutrophil-specific antimicrobial peptides human neutrophil peptides 1–3 (HNP1–3) were quantified by Western immunoblotting. Results Lipids, including cholesteryl esters, were identified in the maxillary sinus secretions of patients with and without CRS. However, levels of lipid composition differed between the two groups with CRS patients exhibiting greater amounts of all classes of lipids, reaching over 10-fold higher concentration when compared with non-CRS patients. This increase was independent of HNP1–3 content. Conclusion Sinus secretions of patients with CRS appear to show elevated levels of antimicrobial lipids compared with controls independent from neutrophil influx. This up-regulation suggests that host-derived lipids act as mediators of mucosal immunity in CRS. Further study is necessary to determine if such antimicrobial lipids function alone or synergistically with antibacterial peptides in conferring such inherent microbicidal properties.

Sinonasal respiratory epithelial adenomatoid hamartomas: Series of 51 cases and literature review

Background Respiratory epithelial adenomatoid hamartomas (REAHs) are rare, benign glandular proliferations of the nasal cavity, paranasal sinuses, and nasopharynx. This study aimed to expand our understanding of this entity by presenting a series of REAHs combined with a review of the pertinent literature. Methods A retrospective review was performed on all patients with a diagnosis of REAH from 2002 to 2011. Data were collected with respect to age, gender, clinical presentation, imaging, histopathology, treatment, and outcome. Because olfactory cleft expansion by imaging evaluation has been reported to suggest REAH, maximum olfactory cleft (MOCs) widths were also measured. Results Fifty-one cases of REAH included 37 male (72.5%) and 14 female subjects (27.5%) with a mean age of 58.4 years. Headache, nasal obstruction, rhinorrhea, and hyposmia were the most common presenting symptoms. Although 35(68.6%) were associated with concurrent inflammatory pathology, 16 (31.4%) presented as isolated lesions of the nasal cavity. Enlargement of MOCs was evident on computed tomography, with mean MOCs of 8.64 and 9.4 mm, in the coronal/axial planes, respectively. There were no statistically significant differences between MOCs of isolated (7.96 mm) versus MOCs of associated (9.63 mm) lesions (p = 0.25). Forty-nine were treated with endoscopic resection without evidence of recurrence after a mean follow-up of 27.2 months. Conclusion REAHs are rare sinonasal lesions that may appear as localized, isolated masses or more diffuse when in conjunction with other inflammatory processes. Irrespective of clinical presentation, endoscopic removal appears to be curative. Differentiation from more aggressive lesions is paramount to avoid unnecessarily radical surgery for an otherwise benign process.

Topical anti-infective sinonasal irrigations: Update and literature review

Background Sinonasal anti-infective irrigations have emerged as a promising therapeutic modality in the comprehensive management of chronic rhinosinusitis (CRS), particularly in the context of recalcitrant disease. The purpose of this article was to delineate the current spectrum of topical anti-infective therapies available and evaluate their role in the treatment of CRS. Methods A systematic literature review was performed on all studies investigating the use of topical antimicrobial solutions in the medical therapy of CRS. Anti-infective irrigations were stratified into topical antibacterial, antifungal, and additive preparations according to their composition and respective microbicidal properties. Results The use of topical antibiotic irrigations has been supported by low-level studies in the treatment of refractory CRS, with optimal results achieved in patients who have undergone prior functional endoscopic sinus surgery and received culture-directed therapy. Multiple evidence-based reviews have not established any clinical benefit with the administration of topical antifungals, and their use is not currently recommended in the management of routine CRS. Topical additives including surfactants may be beneficial as adjunctive treatment for recalcitrant CRS, but additional research is needed to investigate their efficacy in comparison with other agents and establish safety profiles. Conclusion Topical anti-infective solutions are not recommended as first-line therapy for routine CRS but may be considered as a potential option for patients with refractory CRS who have failed traditional medical and surgical intervention. Additional research is necessary to determine which patient populations would derive the most benefit from each respective irrigation regimen and identify potential toxicities associated with prolonged use.

Microbiome of the paranasal sinuses: Update and literature review.

Background Our understanding of the resident microbiome of the paranasal sinuses has changed considerably in recent years. Once presumed to be sterile, healthy sinus cavities are now known to harbor a diverse assemblage of microorganisms, and, it is hypothesized that alterations in the kinds and quantities of these microbes may play a role in the pathogenesis of chronic rhinosinusitis (CRS). Objectives To review the current literature regarding the sinus microbiome and collate research findings from relevant studies published to date. Methods A systematic literature review was performed on all molecular studies that investigated the microbial communities of the paranasal sinuses. Methods of detection, microbiome composition, and comparative profiling between patients with and without CRS were explored. Results A complex consortium of microorganisms has been demonstrated in the sinuses of both patients with and without CRS. However, the latter generally have been characterized by reduced biodiversity compared with controls, with selective enrichment of particular microbes (e.g., Staphylococcus aureus). Such disruptions in the resident microbiome may contribute to disease pathogenesis by enhancing the virulence of potential pathogens and adversely modulating immune responses. Conclusion The advent of culture-independent molecular approaches has led to a greater appreciation of the intricate microbial ecology of the paranasal sinuses. Microbiota composition, distribution, and abundance impact mucosal health and influence pathogen growth and function. A deeper understanding of the host-microbiome relationship and its constituents may encourage development of new treatment paradigms for CRS, which target restoration of microbiome homeostasis and cultivation of optimal microbial communities.

In-office use of a steroid-eluting implant for maintenance of frontal ostial patency after revision sinus surgery

Achieving long-term, successful outcomes with endoscopic sinus surgery (ESS) can be challenging in patients with recalcitrant chronic rhinosinusitis (CRS). Local complications, including scar formation and ostial stenosis, can lead to recurrent blockage and subsequent relapse. The frontal sinus is particularly vulnerable to surgical failure given its narrow outflow and inaccessibility to topical therapies. The advent of steroid-eluting sinus implants has enhanced ESS outcomes, with significant reductions in synechiae, inflammation, and secondary postoperative interventions when placed in the ethmoid cavity. However, use of this technology in the frontal sinus has yet to be described. The purpose of this report is to present two cases, in which in-office frontal placement of a mometasone furoate (MF)-eluting implant facilitated maintenance of ostial patency after revision ESS. The clinical presentation, in-office intervention, and treatment outcomes were examined. Two patients (male, 63 and 68 years of age) with a history of multiple ESS presented with recurrent unilateral frontal headache refractory to medical therapy. Nasal endoscopy/imaging revealed frontal sinus outflow obstruction. Both declined revision ESS under general anesthesia and underwent endoscopic frontal sinustomy/ostial dilation in the clinic. A MF-eluting implant was placed in the frontal sinus at the end of the procedure, with preservation of ostial patency upon last follow-up at 3 and 11 months, respectively. In-office placement of a MF-eluting implant successfully maintained frontal ostial patency in patients with a history of multiple ESS. Additional randomized trials are necessary to determine statistical significance, cost-effectiveness analysis, and long-term efficacy of frontal sinus implantation.

Inverted papilloma of the sphenoid sinus: risk factors for disease recurrence.

Surgical treatment of inverted papilloma (IP) of the sphenoid sinus is complicated by close proximity to vital structures of the skull base. Identifying the site of tumor attachment and achieving complete removal can be challenging compared to IP at other sites. The objective of this study is to illustrate the clinical presentation, management, and risk factors for tumor recurrence for sphenoid IP.

Practice patterns in endoscopic skull base surgery: survey of the American Rhinologic Society

The introduction of advanced endoscopic techniques has facilitated significant growth in the field of endoscopic skull base surgery (SBS). The purpose of this study is to evaluate the impact of endoscopic SBS on the clinical practice patterns of the American Rhinologic Society (ARS) membership.