John P. Bent

The Frontal Cell as a Cause of Frontal Sinus Obstruction

The frontal cell is a rare anatomic anomaly that can become the etiology of chronic frontal sinusitis. It is an anterior ethmoid cell that can be differentiated from other ethmoid cells by serial analysis of sinus CT scans. Located cephalad to the middle meatus, it may obstruct natural mucociliary clearance by impinging on the frontal recess or the frontal sinus cavity. A classification of 4 types frontal cell (Type I-IV) is described. This anatomy is demonstrated in radiographic images of cadaver and patient sinuses. Four consecutive clinical cases of frontal cell obstruction of the frontal sinus are reviewed. In three instances, we performed a combined external and endoscopic intranasal frontal sinusotomy to effectively relieve the obstruction. We describe this technique in detail and provide a mean follow-up of 6 months for these four patients. With recognition of frontal cell obstruction of the frontal sinus, and proper treatment, the results appear to be very rewarding.

Fungal Sinusitis: an Update

OBJECTIVEnTo review the classification of fungal sinusitis as well as discuss current approaches to diagnosis and management.nnnDATA SOURCESnA MEDLINE literature search was performed using the index terms sinus infection, fungal, diagnosis, radiology, microbiology, and treatment. The search was restricted to the English language and human subjects. With one exception the references were restricted to the last 10 years. Clinical data from studies performed at our institution were also included.nnnRESULTSnFungal sinusitis can be divided into four primary categories: (1) acute/fulminant (invasive), (2) chronic/indolent (invasive), (3) fungus ball, and (4) allergic fungal sinusitis. Each subtype has unique immunologic, pathologic, and clinical features. Allergic fungal sinusitis is the most recently described and most common form. The treatment and prognosis of fungal sinusitis varies significantly among the four different categories.nnnCONCLUSIONnRecent advances in endoscopy and computed tomography have enhanced the understanding of fungal sinusitis; however, they remain diseases surrounded by controversy. New insights into the etiology and pathogenesis of these diseases along with advances in diagnosis and treatment will lead to improved medical therapy.

Meta-Analysis of Outcomes of Pediatric Functional Endoscopic Sinus Surgery†

Objective: To create a consensus of outcomes of pediatric functional endoscopic sinus surgery (FESS) and assess its effectiveness and safety.

Acute laryngeal trauma: a review of 77 patients.

Acute laryngeal trauma is a rare injury. In the past 18 years, 77 patients with acute laryngeal trauma have been evaluated at our institution. Each patients care was overseen by the senior author (E.S.P.). The 61 patients who were seen within 48 hours of their accident are compared with those treated after 48 hours. All patients are classified by both injury (groups 1 through 5) and treatment (types I through III). Results are reported for voice, airway, and swallowing. Our methods of evaluation and treatment are outlined, and controversial aspects of patient management are addressed. We conclude that conservative treatment of group 1 and 2 injuries is 100% effective, expeditious repair of laryngeal injuries greatly reduces poor outcome, and the type of injury can be used to roughly predict patient outcome. Further, with use of current methods of diagnosis and management, almost all patients will be decannulated (98%) with functional speech (100%) and normal deglutition (100%). (OTOLARYNGOL HEAD NECK SURG 1993;109:441-9.)

Antifungal Activity Against Allergic Fungal Sinusitis Organisms

A review of more than 50 allergic fungal sinusitis (AFS) patients indicates that most patients experience postoperative recurrences once weaned from oral steroids, leaving a glaring need for improved treatment. Topical antifungal therapy has not been described for AFS, but it could potentially lower fungal antigen loads via postoperative irrigations. No information exists to direct the choice of antifungal agent. The purpose of this study was to identify the appropriate drug to use for postoperative irrigations in AFS patients.

Zenker's diverticulotomy using the ktp/532 laser

Multiple forms of surgical treatment exist for Zenkers diverticulum. Appropriate treatment needs to be tailored based on the needs of the patient and the resources and skills of the surgeon. We have reviewed the available surgical options and presented a series of 10 patients treated with a new technique, the KTP/532 laser diverticulotomy. The diverticulotomy is particularly well-suited to the debilitated patient who cannot tolerate a prolonged operation or a prolonged postoperative recovery. The results of the technique are comparable with those of other forms of diverticulotomy, and it is concluded that the KTP/532 laser is a simple, safe, and effective form of surgical treatment with exciting potential for future use.

Suprastomal Granulation Tissue and Pediatric Tracheotomy Decannulation

Although numerous decannulation techniques have been reported, often involving costly sleep studies, repetitive laser procedures, and tracheotomy tube “downsizing,” no established standard of care exists. We advocate the following simple, minimally invasive decannulation protocol. After excluding concomitant airway lesions, suprastomal granulation is removed transtomally by an endoscopically guided rongeur. A tracheotomy tube is then fashioned with a fenestration centered in the tracheal lumen. Decannulation occurs if the patient maintains adequate ventilation over a 12‐ to 24‐hour observation period with the fenestrated tracheotomy capped. Over 18 months we prospectively followed 10 consecutive children presenting as potential decannulation candidates. Using the aforementioned technique, nine of 10 patients were successfully decannulated (average follow‐up, 11.5 months). The postoperative capped fenestrated tracheotomy trial provides a realistic assessment of preparedness for decannulation. We recommend this protocol as a rapid, efficient, and cost‐effective means of achieving decannulation.

The Management of Blunt Fractures of the Thyroid Cartilage

Our experience with 20 cases of blunt fractures of the thyroid cartilage encountered over the last 15 years were reviewed. These injuries were classified into one of three categories: nondisplaced with minimal associated laryngeal injuries (four cases), moderately displaced with intralaryngeal defects (12 cases), and severe fractures with intralaryngeal avulsion injuries (four cases). Treatment consisted of either surgical reduction of fracture (and associated intralaryngeal injuries) or conservative, nonsurgical management. Results were graded subjectively as good, fair, or poor for airway and voice.

Complications resulting from treatment of severe posterior epistaxis

Recent advances in nasal endoscopy and arterial embolization have improved the treatment of severe posterior epistaxis. This report reviews the therapeutic options, including a case of epistaxis that did not respond to nasal packing but was successfully controlled with superselective arterial embolization. The discussion includes an outline of potential complications of epistaxis treatment, including a case of nasal septal perforation.

Endoscopic Repair of Type IA Laryngeal Clefts

Laryngotracheoesophageal clefts (LTECs) are rare anomalies of the posterior larynx and membranous trachea that may be relatively minor or may extend into the main bronchi. Minor clefts are characterized by deficiency of interarytenoid tissue as the sole anomaly, and as a consequence, the interarytenoid notch lacks height, parallels of the level of the vocal folds in the axial plane, and places patients at risk for aspiration or inspiratory stridor. When limited to the posterior supraglottis, the cleft is known as an Evans I, Benjamin I, or Armitage IA (Table I) (1-5). Henceforth, this cleft will be referred to as type IA laryngeal cleft (IA LC). All forms of LCs are uncommon, present in 11/427 (2.6%) of stridorous patients presenting to a pediatric otolaryngologist (6). In contrast to larger LTECs that typically present in dramatic fashion, the defect of IA LCs easily may be overlooked by the endoscopist. If an IA LC is not considered, symptoms such as chronic cough, recurrent pneumonia, or aspiration may be attributed incorrectly to other causes.