Joseph Brunworth

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.

Inferior turbinate hypertrophy: review and graduated approach to surgical management.

Background Surgical techniques for managing inferior turbinate hypertrophy (ITH) vary widely and have evolved substantially in the past four decades as new technologies have emerged. Methods Literature review. Results Inferior turbinate (IT) procedures can be categorized as: simple turbinate outfracture; turbinoplasty techniques such as extramucosal destruction, and submucosal tissue removal; and extramural turbinate resection (partial or complete). Each of these approaches has advantages and drawbacks. Considerations for technique selection include clinical setting (in-office versus operating room), cost of the devices used, efficacy of the procedure to relieve nasal obstruction, and minimizing postoperative complications such as nuisance bleeding, adhesion formation, and crusting. Conclusion There are a variety of contemporary surgical techniques used for IT reduction. This article highlights the available literature and gaps in current knowledge. A graduated approach to the management of ITH will be presented.

Craniocervical Necrotizing Fasciitis Resulting from Dentoalveolar Infection

Craniocervical necrotizing fasciitis is a rare infectious process that can be life-threatening. It most commonly occurs as a result of a severe dentoalveolar infection. This article reviews the diagnosis, microbiology, anatomy, and pathophysiology behind this infectious process; the incidence; and the recommended treatments and therapies. It is hoped that this article provides the treating health care provider with an up-to-date review of this serious infectious process.

Nasopharyngeal acid reflux and eustachian tube dysfunction in adults

Objective: This study aimed to evaluate the relationship between nasopharyngeal pH and Eustachian tube dysfunction (ETD) in adults. Study Design: Unmatched case-control study. Methods: Forty-one subjects, 20 adults with a diagnosis of ETD and 21 healthy adults as controls, were enrolled from an outpatient clinic. All subjects had a Dx–pH probe placed near the torus tubarius in the posterior nasopharynx for 24 hours. The pH values were recorded every 0.5 second. Decreases in pH were considered as reflux events if the pH dropped below 5.5. Results: The average nasopharyngeal pH value was 6.90 (range, 5.33-7.73) in the subjects with ETD and 7.07 (range, 5.99-7.94) in the controls. The difference between the 2 groups was not statistically significant (P = .30). The ETD group, on average, had a higher number of nasopharyngeal reflux events (2.3 ± 1.6 vs 0.8 ± 1.2, respectively; P = .002) and higher reflux finding score (3.6 ± 2.7 vs 0.4 ± 1.4, respectively; P < .001) than the control group. Conclusion: By using a novel pH probe that allows detection of acidity in a nonliquid environment, a comparison of nasopharyngeal pH between control patients and those with ETD was performed. Eustachian tube dysfunction was more likely to be associated with a higher number of nasopharyngeal reflux events and higher reflux finding score. Nasopharyngeal reflux may have a role in the pathogenesis of ETD.

Intracranial mucocele formation in the context of longstanding chronic rhinosinusitis: A clinicopathologic series and literature review

Chronic rhinosinusitis (CRS) can lead to serious long-term adverse sequelae, particularly if left untreated. The aim of this study was to describe a series of intracranial mucoceles (ICMs) that arose in the context of longstanding CRS combined with a review of the pertinent literature. A retrospective chart review was performed on all patients who developed ICMs in association with CRS between 2003 and 2012. The clinical presentation, radiographic features, surgical approach, intraoperative findings, and patient outcome were examined in the context of a literature review. Sixty-five cases of mucoceles were identified in patients with a history of CRS, of which seven (10.8%) were intracranial. Five patients were men and two were women with a mean age of 42.1 years. Headache, facial pressure, retro-orbital pain, and visual disturbances were the most common presenting symptoms. Five of the seven had previously undergone sinonasal surgery. Imaging studies showed ICMs involving the anterior cranial fossa, two of which were bilateral. Latency between onset of CRS and ICM detection ranged from 3 to 19 years (mean, 9.4 years). All patients underwent endoscopic transnasal drainage with three also requiring a concurrent, open neurosurgical procedure to access the intracranial component. There were no postoperative complications, and no recurrences were observed after a mean follow-up of 2.7 years. ICMs presenting as delayed complications of CRS are uncommon and constitute a surgical challenge. Open, external skull base approaches used in conjunction with transnasal endoscopic drainage procedures may be necessary to achieve successful management of this rare condition.Chronic rhinosinusitis (CRS) can lead to serious long-term adverse sequelae, particularly if left untreated. The aim of this study was to describe a series of intracranial mucoceles (ICMs) that arose in the context of longstanding CRS combined with a review of the pertinent literature. A retrospective chart review was performed on all patients who developed ICMs in association with CRS between 2003 and 2012. The clinical presentation, radiographic features, surgical approach, intraoperative findings, and patient outcome were examined in the context of a literature review. Sixty-five cases of mucoceles were identified in patients with a history of CRS, of which seven (10.8%) were intracranial. Five patients were men and two were women with a mean age of 42.1 years. Headache, facial pressure, retro-orbital pain, and visual disturbances were the most common presenting symptoms. Five of the seven had previously undergone sinonasal surgery. Imaging studies showed ICMs involving the anterior cranial fossa, two of which were bilateral. Latency between onset of CRS and ICM detection ranged from 3 to 19 years (mean, 9.4 years). All patients underwent endoscopic transnasal drainage with three also requiring a concurrent, open neurosurgical procedure to access the intracranial component. There were no postoperative complications, and no recurrences were observed after a mean follow-up of 2.7 years. ICMs presenting as delayed complications of CRS are uncommon and constitute a surgical challenge. Open, external skull base approaches used in conjunction with transnasal endoscopic drainage procedures may be necessary to achieve successful management of this rare condition.

Detecting nasopharyngeal reflux: a novel pH probe technique.

Objectives: We sought to ascertain the normal pH values in the aerosolized environment of the nasopharynx in healthy subjects and utilize a novel pH probe that allows measuring acidity in a nonliquid environment. Methods: Between November 2009 and February 2011, healthy volunteers without a history of reflux or eustachian tube dysfunction were enrolled in the prospective study. A total of 20 subjects had a Dx–pH Measurement System Probe (Respiratory Technology Corp) placed near the torus tubarius. The pH probe records the pH throughout the 24-hour study. A pH below 5.5 while the subject was upright or below 5.0 while the subject was supine was used as a criterion to determine a reflux event. Recording was stopped during meals. Results: For normal individuals with no history of reflux or eustachian tube dysfunction, the pH values obtained from the nasopharynx ranged from 6.10 to 7.92. The average pH was 7.03 (SD, 0.67). Eight subjects (40%) had at least 1 reflux event during the 24-hour pH study. Conclusions: By utilizing a novel self-condensing pH probe, we were able to perform a 24-hour pH study in the nasopharynx of 20 healthy individuals. In our study, the average pH for individuals without symptomatic reflux or eustachian tube dysfunction was 7.03. Interestingly, 8 control subjects had at least 1 episode of pH below 5.5 while awake or below 5.0 while asleep, which was considered to be a reflux event in our study.

Use of the Hadad-Bassagasteguy flap for repair of recurrent cerebrospinal fluid leak after prior transsphenoidal surgery

The Hadad-Bassagasteguy vascularized nasoseptal pedicled flap (HBF) is an effective technique for reconstruction of skull base defects with low incidence of postoperative cerebrospinal fluid (CSF) leak. Advanced planning is required as posterior septectomy during transsphenoidal surgery can preclude its use due to destruction of the vascular pedicle. We present four cases in which the HBF was successfully used to repair recurrent CSF leaks despite prior posterior septectomy and transsphenoidal surgery. A retrospective chart review was performed on all patients who developed recurrent CSF leak after transsphenoidal surgery over a 7-year period (2006–2013). Data were collected regarding demographics, clinical presentation, intraoperative findings, and surgical outcomes. Four patients who developed recurrent CSF drainage after transsphenoidal surgery were managed with HBF reconstruction during the study period. Two were men and two were women with a mean age of 37 years (range, 24–48 years). All had previously undergone resection of a pituitary macroadenoma via a transsphenoidal approach, with intraoperative CSF leaks repaired using multilayered free grafts. Recurrent CSF rhinorrhea arose 0.37–12 months (mean, 2.98 months) after the initial pituitary surgery. Active CSF drainage could be visualized intraoperatively with posterior septal perforations present. The HBF was successfully used in all cases, with no evidence of recurrent CSF leak after a mean follow-up of 2.35 years. The HBF may be salvaged for repair of recurrent CSF leaks even in the context of prior posterior septectomy and transsphenoidal surgery. However, longer follow-up is necessary to determine the long-term efficacy of this procedure in such revision cases.

Accuracy of Tinnitus Pitch Matching Using a Web-Based Protocol

Objectives: We investigated the accuracy of a web-based protocol for tinnitus frequency matching compared to that of tinnitus pitch matching performed by an audiologist using an audiometer in an anechoic chamber. Methods: Twenty subjects underwent tinnitus frequency-matching in a random order using an audiometer in an anechoic chamber and using web-based software with a multiple-choice protocol in octave or half-octave steps from 250 Hz to 12,000 Hz and a slider in 25-Hz steps from 20 to 20,000 Hz. Octave challenge testing was performed. The participants were asked to indicate which protocol resulted in the closest match to their tinnitus frequency. Results: The median tinnitus frequency was 6,000 Hz (range, 2,000 to 12,000 Hz) with use of the audiometer and self-directed multiple-choice protocol. With the slider, the median frequency was 5,925 Hz (range, 1,850 to 16,000 Hz). The patients with a tinnitus frequency higher than 12,000 Hz experienced a greater level of satisfaction when using the computer-based slider system. Five patients experienced octave confusion with self-directed multiple-choice tinnitus matching that was corrected accurately after the octave challenge step. Conclusions: A web-based protocol for tinnitus frequency matching is as accurate as a standard audiometric protocol. An octave challenge test might be necessary for patient-directed tinnitus frequency matching.

Accuracy of Tinnitus Matching Using a Web-Based Protocol

Objective: 1) Learn whether a web-based protocol can be used to match tonal tinnitus. 2) Compare the accuracy of a web-based protocol with tinnitus matching using an audiometer. Method: Twenty subjects had tinnitus frequency matching using an audiometer in an anechoic chamber using a standard protocol. The subjects then matched their tinnitus at a desktop computer in an examination room using a web-based protocol with a multiple choice and a slider. Octave challenge testing was performed. Results: The age ranged between 30 and 77 years (median age, 53.5 years). Median tinnitus frequency was 6000 Hz (range, 2000-12000 Hz) using the audiometer and multiple choice self-directed protocol. Using the slider, the median frequency was 5925 Hz (range, 1850-16000 Hz). The patients with tinnitus frequency of over 12000 Hz experienced a higher level of satisfaction with their tinnitus match when using the computer-based slider system. Five patients (25%) experienced octave confusion (matched to a frequency one octave below or above) when performing self-directed multiple choice tinnitus matching. These patients accurately matched their tinnitus frequency after the octave challenge step. Conclusion: A web-based protocol for tinnitus frequency matching is as accurate as a standard protocol. Patients with very high frequency tinnitus preferred a web-based slider. Patients may inaccurately identify their tinnitus frequency as one octave above or below. An octave challenge test is necessary for a patient-directed tinnitus frequency matching.

Detecting Reflux in Adults with Eustachian Tube Dysfunction

Objective: 1) Ascertain whether adult patients with Eustachian tube dysfunction (ETD) have a higher incidence of reflux into the nasopharynx compared with controls. 2) Utilize recent advances in pH probe technology to detect acidity at the Eustachian tube orifice for direct comparison. Method: A prospective study was performed on 38 adult patients in an outpatient setting between November 2009 and February 2011. Seventeen patients with Eustachian tube dysfunction and 21 control subjects had a Dx-pH probe (Restech, San Diego, California 2006) placed near the torus tubarius in the posterior nasopharynx for 24 hours. Results: The average pH value obtained from the nasopharynx of adults with no history of ETD was 7.03 (range, 6.10-7.92; SD, 0.69). In comparison, the average pH for patients with ETD was 6.90 (range, 5.33-8.06; SD, 0.77). This P value for this difference was .48. The average number of reflux events for subjects was 0.55 events over a 24-hour period for controls and 2.1 for patients with ETD. Decreases in pH were considered reflux events if the pH dropped below 5.5 while in the upright position or below 5.0 in the supine position. Conclusion: By utilizing a novel pH probe that allows detection of acidity in a non-liquid environment, a comparison of nasopharyngeal pH between control patients and those with ETD was performed. A trend toward higher numbers of reflux events was found in patients with ETD when compared to control subjects.