João Subtil

Helicobacter pylori and laryngopharyngeal reflux in chronic rhinosinusitis.

OBJECTIVES: Investigation of the potential role of several laryngopharyngeal reflux contents in sinus disease. STUDY DESIGN AND SETTING: A controlled cohort analysis of Helicobacter pylori, pepsin and pepsinogen I in inflamed and non-inflamed sinonasal tissue. Fifteen patients, selected for surgery due to chronic medically refractory rhinosinusitis, had their pathologic sinus tissue analyzed for polymerase chain reaction detection of H. pylori DNA and assayed for pepsin and pepsinogen I tissue concentration levels. A control group of 5 patients undergoing surgery for anatomic sinonasal abnormalities provided non-inflammatory mucosa specimens for comparison. RESULTS: H. pylori was found scattered in inflamed and non-inflamed mucosa, whereas sinonasal tissue pepsin/pepsinogen never rose above blood levels in both groups. CONCLUSIONS: Evidence of intra-operative peptic reflux into the sinuses was not found. As H. pylori was similarly encountered in healthy and diseased sinus mucosa, it seemingly fails to support a pathogenic role for this organism in the sinuses. EBM rating: B-2b

Endonasal endoscopic repair of the orbital floor defect in the silent sinus syndrome

The “silent sinus syndrome” defines a rare condition in which eyeball retraction, or enophthalmos, with or without diplopia, spontaneously occurs in a patient who displays some form of asymptomatic chronic maxillary atelectasis. Persistent ostial blockage, hypoventilation with longstanding negative intrasinus pressure, along with retention of secretions, antral walls bone remodeling, and inferior displacement of the orbital floor, ultimately risking herniation of the orbital contents in the sinus cavity, seem to hallmark this entity. Authors agree that management includes a prompt surgical drainage of the occluded sinus; the current trends favor an endoscopic approach to the maxillary antrum with the creation of an intranasal antrostomy. The specific management of the orbital floor anatomic abnormality is, however, still subject to debate. Some contend that the antral drainage is frequently sufficient, as the ensuring sinus healing will naturally retract the sinus cavity and thus correct the enophthalmos. Others maintain that some sort of orbital floor augmentation procedure may also, at times, be needed, and favor sameor second-stage orbital floor reconstruction, with the use of some type of implant material. We present a silent sinus syndrome case on which, at the same-stage a wide middle meatal antrostomy was created for maxillary sinus drainage, an endoscopic transnasal/ transantral technique successfully addressed the repair of a large orbital floor defect using autogenous materials. A 35-year-old man was referred to ENT care after having been seen by an ophthalmologist because of a 3 mm left eye enophthalmos of five months duration, normal visual acuity, and unaffected intraocular pressure and

Chronic Rhinosinusitis and Lacrimal Obstructive Disease

Objective: To investigate if chronic inflammatory sinus disease has a pathogenic role in the obstructive pathology of the neighboring lacrimal system, including obstruction alone and chronic or recurring dacryocystitis. Method: One hundred patients were selected for endoscopic DCR because of persistent epiphora and/or chronic or recurrent dacryocystitis. Their sinus CT scans were evaluated using the Lund-Mackay score.The nonoperated side and a further group of 30 head trauma patients were the control groups. Results: No statistically significant differences were found in either presence or absence, or even disease extension or location, of image defined inflammation of the sinuses and obstructive pathology of the lacrimal system, including chronic or recurring dacryocystitis. DCR sides and patients do not have higher scores of sinonasal disease than nonsurgical sides or normal subjects. Conclusion: These results lead to the conclusion that chronic inflammatory sinus disease is a comorbidity that very likely does not play a pathogenic role in any form of obstructive disease of the lacrimal system.

Endonasal Endoscopic Repair of Orbital Floor Defects

Objective: We have previously published an endonasal endoscopic technique of inferior orbital floor reconstruction, for the surgical management of the “silent sinus syndrome” and “blow-out” orbital fractures. Based on the same principles, we present an alternative version of the technique with the advantage of an “overlay” approach to the bone defect. Method: After creating a large middle meatal antrostomy, an autologous septal bone graft is placed over the orbit floor defect, in the subperiostal plane between orbital contents and bony floor, through an incision on the lamina papyracea. Results: At long-term follow-up we achieve, in most, if not all, cases, resolution of enophthalmos and ipsilateral chronic maxillary sinus atelectasis, with minimal morbidity. Conclusion: This technique provides excellent functional and aesthetic results in the surgical reconstruction of the orbit floor.