Marc G. Dubin

American Rhinologic Society member survey on "maximal medical therapy" for chronic rhinosinusitis.

Background “Maximal medical therapy” is the standard of care for chronic rhinosinusitis (CRS) treatment before the recommendation for surgery. However, this therapy is not consistent. Therefore, as a first step in determining the role of the disparate “maximal medical” treatments for CRS, American Rhinologic Society (ARS) members were surveyed. Methods A survey was mailed to all nonresident members of the ARS (n = 723). Focusing on the time period before surgical intervention is first considered for CRS patients, the survey assessed types of therapies, frequency of use, details on antibiotic and steroid usage, use of computed tomography (CT), and demographic data of respondents. All responses were anonymous. Results Three hundred eight surveys were returned (43%). A majority of respondents used oral antibiotics and nasal steroids “almost always (>90%).” Oral antibiotics, oral steroids, nasal steroids, saline irrigation, and allergy testing were most commonly used at least “usually (50–90%).” The median antibiotic length was 3.1–4 weeks. The mean peak prednisone dose was 51.7 mg when oral steroids were used. Therapies that were rarely or never used by the majority included oral antifungals, antifungal spray, antibiotic spray, antibiotic nebulizer, steroid nebulizer, and i.v. antibiotics. Conclusion Oral antibiotics (median, 3.1–4 weeks) and nasal steroids are used >90% of the time by a majority of ARS members for maximal medical treatment of CRS.

Sinonasal epithelial cell expression of toll-like receptor 9 is decreased in chronic rhinosinusitis with polyps

Background Innate immune recognition of pathogens by sinonasal epithelial cells may play an important role in the pathogenesis of chronic rhinosinusitis (CRS). Previous studies have indicated that toll-like receptor (TLR) mRNA is present in sinonasal mucosa, and levels of TLR9 expression are decreased in recalcitrant CRS with nasal polyps (CRSwNP). However, the cellular source and function of TLR9 in the sinonasal epithelium is not known. In this study, primary epithelial cell cultures were analyzed from control subjects and CRSwNP patients to determine the presence and function of TLR9 protein. Methods Primary epithelial cell cultures were established from 5 controls and 10 CRSwNP patients undergoing sinus surgery. Flow cytometry was used to confirm purity of epithelial cells and to assess expression of TLR9 protein. Epithelial cells were stimulated with TLR9 agonist, and mRNA was analyzed by real-time PCR for expression of human β-defensin (HBD) 2 and interleukin (IL)-8. Results Flow cytometry showed TLR9 protein in 100% of epithelial cells from controls and CRSwNP patients. The level of expression was 50% lower in CRS patients than in controls. Stimulation of epithelial cells with TLR9 agonist produced a 1.5- to 9-fold increase in HBD-2 and IL-8 mRNA expression. Conclusion Functional TLR9 protein is expressed by normal and diseased sinonasal epithelial cells. The level of TLR9 expression is decreased in CRSwNP patients, consistent with the previous finding of decreased TLR9 mRNA in whole sinonasal tissue. These findings suggest that impaired innate immune responses to pathogens via TLR9 on sinonasal epithelial cells may represent a critical mechanism in chronic inflammatory sinus disease.

Allograft dermal implant (AlloDerm) in a previously irradiated field.

Objective To evaluate the integration of AlloDerm (LifeCell Corp., The Woodlands, TX) in a field exposed to external‐beam radiation (EBR) by analyzing graft thickness, fibroblast recellularization, and neovascularization.

Endoscopic Repair of Cerebrospinal Fluid Leaks After Neurosurgical Procedures

OBJECTIVES Endoscopic repair of cerebrospinal fluid (CSF) leaks has proven to be effective and safe. CSF rhinorrhea is a well-known complication of neurosurgical procedures in the anterior cranial fossa. We present a series of endoscopic repairs of CSF rhinorrhea secondary to neurosurgical procedures. STUDY DESIGN Retrospective review of 13 cases. METHODS Thirteen patients are included in the study. Eleven had CSF leaks after hypophysectomy, one after clipping of an anterior circle of Willis aneurysm, and one after posttraumatic frontal lobe debridement. Leaks were identified intraoperatively during the neurosurgical procedure (n = 8) or with intrathecal fluorescein injection during a separate procedure (n = 5). Repair was performed by exposing the skull base defect, debriding the defect margins, and sealing the defect with a free mucosal graft or abdominal fat. RESULTS Leaks were identified in the sphenoid (n = 12) and posterior ethmoid (n = 1) sinuses. Nine patients had lumbar drains placed. One patient had recurrence of CSF rhinorrhea 2 months after initial repair requiring a revision procedure. No other recurrences were noted. One patient developed postoperative meningitis requiring intravenous antibiotics and a prolonged hospital stay. No other postoperative complications were observed. CONCLUSIONS Endoscopic repair is a safe and effective treatment for CSF rhinorrhea encountered as a neurosurgical complication.

Clear cell odontogenic carcinoma: A comprehensive analysis of treatment strategies

Odontogenic neoplasms of predominately clear cells are unusual. They represent a diagnostic dilemma, and as a result, treatment strategies are diverse. Our goal is to present two new cases, summarize reported cases of clear cell odontogenic carcinoma (CCOC), assess potential risk factors for recurrence, and propose definitive surgical and therapeutic strategies.

A comparison of computer-aided surgery registration methods for endoscopic sinus surgery.

Background Stereotactic computer-aided surgery has provided the surgeon with a means to navigate more safely through diseased or surgically altered sinus anatomy. Accurate registration is vital to successful image-guided surgery. This study compared the accuracy and performance of three registration methods: fiducial, anatomic landmarks, and surface registration. Methods Ten fixed cadaveric heads underwent endoscopic computed tomography scan followed by middle meatal antrostomy and sphenoidotomy. Each registration method was performed, and the time required and mean registration error were recorded. Five anatomic sites were then identified and compared with the preoperative computed tomography images. The true distances between the known anatomic sites and the crosshair locations on the images were measured. Results Statistically significant differences were noted for mean registration error and time for registration. The mean ± SEM time for registration for the fiducial, surface, and landmark methods were 5 minutes 24 seconds ± 27 seconds, 1 minute 1 second ± 5 seconds, and 11 minutes 46 seconds ± 45 seconds, respectively. The mean ± SEM registration error for the fiducial, surface, and landmark methods were 0.48 ± 0.21 mm, 1.05 ± 0.06 mm, and 3.1 ± 0.25 mm, respectively. When the true accuracy of the three registration methods were compared, no significant difference was found between fiducial and surface registration. However, fiducial registration was significantly more accurate than landmark registration at all points. When compared with landmark registration, surface registration was statistically more accurate at all anatomic sites except for the sella turcica and optic nerve. Conclusion When the true accuracies of these methods were compared infixed cadaveric specimens, fiducial and surface registration were statistically similar but were found to be significantly more accurate than landmark registration. Furthermore, when time of registration, accuracy, and ease of use were considered, surface registration was found superior.

Concordance of middle meatal swab and maxillary sinus aspirate in acute and chronic sinusitis: a meta-analysis.

Background The medical management of acute and chronic sinusitis is a therapeutic challenge. The use of endoscopic middle meatal cultures as a noninvasive method to determine the bacteriology of the maxillary sinus has not accurately been established. The aim of this study was to review the literature that compares cultures obtained by endoscopic middle meatal swabs with those obtained from maxillary sinus aspirates (MSAs). Methods We reviewed studies published between January 1966 and October 2003 that were identified from searches of multiple databases, bibliographies, and original articles. Studies were included for analysis if they compared the results of endoscopic middle meatal cultures to aspirate cultures. All clinical variables and test performances were independently extracted by two reviewers. Results Middle meatal culture had a per isolate accuracy of 82% (95% confidence interval, 0.64, 0.92) compared with MSA (excluding coagulase negative staphylococcus and fungal cultures). Conclusion Endoscopic middle meatal cultures have a high concordance with MSAs.

Staged Endoscopic and Combined Open/Endoscopic Approach in the Management of Inverted Papilloma of the Frontal Sinus

Background The endoscopic management of inverted papilloma has gained increasing popularity over the last 10 years. Although early concerns over an increased risk of recurrence seem to have been allayed, the appropriate management of lesions involving the frontal sinus and frontal recess still has to be determined. Methods We performed a retrospective review of the results of all patients with inverted papilloma from 2000 to 2004. Results A total of 18 patients were treated between October 2000 and January 2004. Six patients had frontal sinus involvement at the time of initial evaluation. One of these patients had isolated frontal sinus involvement. These patients were managed with either initial endoscopic resection with determination for the need for an additional procedure at the time of endoscopic resection (n = 5) or open/endoscopic approach for isolated frontal sinus involvement (n = 1). Of the five patients who had their disease managed endoscopically, three patients were determined at the initial procedure to need an osteoplastic flap and, subsequently, were managed successfully with a combined approach. One other patient was initially successfully managed endoscopically but ultimately required an osteoplastic flap for definitive management. The fifth patient was managed entirely endoscopically with multiple procedures. All patients treated with this protocol remain disease free with an average follow-up of 13.3 months. Conclusion The limitations of endoscopic resection of inverted papilloma of the frontal recess can be managed with staged procedures. Initial endoscopic resection of ethmoid/maxillary disease with subsequent open treatment of the frontal sinus has been successful in our experience.

Preservation of Natural Frontal Sinus Outflow in the Management of Frontal Sinus Osteomas

INTRODUCTION: Management of frontal sinus tumors has traditionally been through open approaches with obliteration of the sinus. Recently, increased comfort with endoscopic techniques has made endoscopic resection an alternative to more morbid approaches. However, many skilled endoscopists still champion obliteration of the frontal sinus after the open treatment of large osteomas. METHODS: A retrospective review of the senior authors experience with frontal sinus osteomas was performed. RESULTS: Twelve frontal sinus osteomas were treated surgically without obliteration. All patients with greater than 2 cm vertical extension of their tumor into the frontal sinus required an open approach (n = 4), whereas the remainder (n = 8) were treated endoscopically. Frontal ostia were stented if greater that 40% of the mucosa of the frontal recess was denuded. Eleven of 12 patients had patent, functional frontal sinuses. CONCLUSION: Successful resection of frontal sinus osteomas can be performed with preservation of the natural drainage of the frontal sinus in almost all cases. EBM rating: C-4

Effect of intranasal histamine challenge on Eustachian tube function

OBJECTIVE To show a relationship between intranasal histamine challenge, the development of middle ear effusion and Eustachian tube (ET) dysfunction in a rat model. METHODS Non-allergic Sprague-Dawley rats weighing between 450-600 g were randomly assigned to receive an intranasal infusion of 16 microl of 10% histamine or normal saline. ET function was assessed by using the forced-response test to measure passive and active opening and closing pressures at time intervals of 6, 10, 14, 18, 22, and 26 min and 24 h post-infusion. Mucociliary clearance times (MCCTs) of the tubotympanum at 18 min post-infusion were measured by timing the transit of dye from the middle ear to the nasopharynx. Outcome measures were ET dysfunction and evidence of clinical effusion. RESULTS Intranasal histamine caused acute ET dysfunction when introduced into the nasopharynx demonstrated by significant elevations in passive and active opening and closing pressures (P < or = 0.001) compared to controls. The largest difference was seen at 26 min post-infusion. Furthermore, MCCTs were 2.4 times longer after infusing intranasal histamine than after saline infusion. No clinically significant effusions were evident in either group at any time interval. CONCLUSION These data demonstrate a successful development of an intranasal histamine rat model, in addition to a relationship between intranasal histamine challenge and development of acute ET dysfunction.