Michael R. Shohet

Isolated sphenoid sinus lesions.

Pathologic conditions involving the sphenoid sinus alone are rare. A retrospective chart review was performed of 182 cases of isolated sphenoid sinus lesions seen at the Mayo Clinic between 1935 and 1998. There were 53 cases of sinusitis, 44 mucoceles, and 15 fungus-related cases (61.5%), and the rest of the cases were divided among numerous other pathologic entities. Symptoms, differential diagnosis, and various therapeutic modalities are discussed. We believe that these data will be useful to clinicians considering multiple pathologic possibilities when faced with a lesion involving the sphenoid sinus alone.

Vocal cord dysfunction in former World Trade Center (WTC) rescue and recovery workers and volunteers

BACKGROUND Vocal cord dysfunction (VCD) is a condition characterized by paradoxical partial adduction of the vocal cords on inspiration. It has been associated with exposures to irritants, as well as with psychological illnesses and conditions. Workers who participated in the recovery of the WTC disaster site were exposed to a large amount of irritants as well as considerable psychological stressors. We describe the clinical characteristics of 10 symptomatic former WTC workers diagnosed with this condition, as well as the frequency of spirometric findings suggestive of variable extrathoracic obstruction. METHODS Workers who became symptomatic after their WTC work experience have been evaluated clinically by a multidisciplinary team at an academic medical center. The evaluation included history, physical examination, chest radiograph, blood tests, and pre- and post-bronchodilator spirometry in all patients. Additional evaluations and diagnostic tests included otolaryngological evaluation with flexible rhinolaryngoscopy and stroboscopy, gastroenterological and psychiatric evaluations. A randomly selected sample of 172 spirometry results were reviewed for evidence of inspiratory flow limitation. RESULTS Variable extrathoracic obstruction was found in 18.6% of the spirometries. Ten patients were diagnosed with VCD. In addition to symptoms suggestive of co-morbid conditions (particularly rhinitis and acid reflux disease), most of the 10 patients had (1) hoarseness, (2) dyspnea that was not associated with bronchial hyperreactivity, or (3) dyspnea associated with asthma, with either mild bronchial hyperreactivity and/or poor response to asthma treatment. CONCLUSIONS VCD appears to be part of the spectrum of airway disorders caused by occupational exposures at the WTC disaster site. Further study of this association is warranted.

Intracranial mucocele: an unusual complication of cerebrospinal fluid leakage repair with middle turbinate mucosal graft.

Cerebrospinal fluid (CSF) leakage is a well-documented complication of endoscopic sinus surgery (ESS). The usual treatment after such an occurrence is immediate repair using either autogenous or alloplastic materials. Autogenous tissues such as turbinate mucosa, septal cartilage and bone with or without mucoperichondrium/mucoperiosteum, fascia lata, and temporalis fascia are all commonly utilized. However, improper use and inadequate placement of autogenous mucosal grafts can lead to avoidable complications. Intracranial mucocele as a complication of CSF fistula repair with autogenous mucosal graft has been documented only once in the literature. We describe a case of intracranial mucocele formation, five years after repair of CSF fistula using autogenous middle turbinate tissue. A 54-year-old white male was referred to our skull base center with a 2-month history of recurrent seizures. Five years prior to presentation, he underwent ESS at an outside institution; the procedure was complicated by a CSF leakage, which was repaired with a middle turbinate mucosal autograft. Nasal endoscopy revealed hyperplastic inflammatory polyps and a right superior ethmoid mass. Magnetic resonance imaging (MRI) of the paranasal sinuses demonstrated an expansile lesion at the anterior skull base with morphological appearance suggestive of an ethmoid mucocele extending into the intracranial compartment (Fig 1). The signal characteristics of this lesion appearing hyperintense on the T1-weighted image (WI) and hypointense on T2-WI were consistent with high-proteinaceous debris within the mucocele. The patient underwent sinus debridement and mucocele excision via a combined transnasal endoscopic and subcranial approach to the anterior cranial fossa with multilayered autogenous fascia lata and vascularized pericranial flap reconstruction. His postoperative course was uncomplicated, and he was discharged home on the third postoperative day. The patient is currently doing well clinically without radiographic evidence of recurrence after two years.

Atopy and upper and lower airway disease among former World Trade Center workers and volunteers.

Objective: A large number of workers seemed to have developed upper and lower airway disease (UAD and LAD, respectively) in relation to their occupational exposures at the World Trade Center (WTC) disaster site. This study examined atopy as a risk factor for presumably WTC-related UAD and LAD. Methods: Atopy was examined in 136 former WTC workers and volunteers by radioallergosorbent test, skin prick testing, or both. Overall prevalence of atopy was estimated, and bivariate and multivariate logistic regression analyses were conducted to examine associations of atopy with WTC-related UAD and LAD. Results: Atopy was prevalent in 54.4% of these WTC workers. Atopy was associated with higher symptom severity scores for both WTC-related UAD and LAD. Atopy was a predictor of WTC-related UAD but not LAD. Early arrival at the WTC site, and pre-2001 asthma diagnosis were predictors of LAD. Conclusion: The prevalence of atopy in this population is similar to what has been described for the general U.S. population. Atopy seemed to be a risk factor for presumably WTC-related UAD but not for LAD.

Occupational Rhinosinusitis and Upper Airway Disease: The World Trade Center Experience

The World Trade Center disaster and its recovery work involved a range of hazardous occupational exposures that have not been fully characterized but that can be reasonably assumed to have the potential to cause mucosal inflammation, preferentially (but not exclusively) in the upper airway. A high prevalence of rhinosinusitis and upper airway disease (UAD) symptoms was reported by several early surveys. Clinical studies demonstrated objective, clinically significant, and persistent chronic perennial rhinosinusitis and UAD—with or without seasonal exacerbation—in a large proportion of patients. Demonstration of an association between UAD and available exposure indicators has been limited. Atopy seemed to be associated with increased UAD symptom severity and to be a risk factor for upper, but not lower, airway disease. World Trade Center-related UAD is considered an irritant-induced disease but not, in many cases, of acute onset. No data thus far suggest an increased upper airway cancer incidence.

Enophthalmos as a Complication of Rhinoplasty

Silent sinus syndrome is a known clinical entity caused by negative sinus pressure from acquired obstruction of the maxillary sinus ostium with resulting enophthalmos and hypoglobus. We present a case in which, after septorhinoplasty, a patient developed progressive enophthalmos and hypoglobus. His evaluation was consistent with silent sinus syndrome. This case illustrates the complex reconstructive challenges of repairing an orbit in the setting of fistulization of the orbit with the maxillary sinus cavity. In particular, we highlight the inferior fornyx transconjunctival approach with simultaneous intranasal endoscopic maxillary sinus aeration.

Demineralized bone matrix and fat autograft in a rabbit model of frontal sinus obliteration

OBJECTIVE: In this study, we investigate the efficacy of demineralized bone matrix (DBM) as a material for frontal sinus obliteration in a rabbit model. STUDY DESIGN AND SETTING: Twenty-four New Zealand White rabbits were divided into four groups, and the study was carried out to two time periods. Twelve rabbits underwent frontal sinus obliteration with fat autograft, and 12 rabbits underwent the procedure with DBM. At 12 weeks, six control and six study rabbits were killed. The remaining 12 rabbits were killed at 36 weeks. All specimens underwent radiologic evaluation with spiral CT followed by histologic examination for evidence of bony growth. RESULTS: Sinuses obliterated with DBM showed replacement of the sinus cavity by trabecular bone. Histology demonstrated significant progressive replacement of DBM by cancellous bone from 12 weeks (53.3%) to 36 weeks (78.8%). There were no complications observed as a result of the materials used. CONCLUSION AND SIGNIFICANCE: DBM is a prospective material for frontal sinus obliteration. Long-term studies and human trials will further elucidate the role of this material.

Blood Eosinophils and World Trade Center Exposure Predict Surgery in Chronic Rhinosinusitis. A 13.5-Year Longitudinal Study

RATIONALE The World Trade Center (WTC) collapse generated caustic airborne particulates that caused chronic rhinosinusitis in exposed Fire Department of New York firefighters. Surgery was performed when symptoms remained uncontrolled despite medical management. OBJECTIVES To identify predictors of surgical intervention for chronic rhinosinusitis in firefighters exposed to airborne irritants at the WTC collapse site. METHODS We assessed in 8,227 firefighters with WTC exposure between September 11, 2001 (9/11), and September 25, 2001, including WTC-site arrival time, months of rescue and recovery work, and eosinophil concentration measured between 9/11 and March 10, 2003. We assessed the association of serum cytokines and immunoglobulins with eosinophil concentration and surgery for rhinosinusitis in 112 surgical cases and 376 control subjects with serum available from the first 6 months after exposure to the WTC collapse site. MEASUREMENTS AND MAIN RESULTS Between 9/11 and March 10, 2015, the surgery rate was 0.47 cases per 100 person-years. In the first 18 months post-9/11, surgical patients had higher mean blood eosinophil levels than study cohort patients (219 ± 155 vs. 191 ± 134; P < 0.0001). Increased surgery risk was associated with increasing blood eosinophil counts (hazard ratio [HR], 1.12 per 100 cells/μl; 95% confidence interval [CI], 1.07-1.17; P < 0.001); arriving at the WTC site on 9/11 or September 12, 2001 (HR, 1.43; 95% CI, 1.04-1.99; P = 0.03); and working 6 months or longer at the WTC site (HR, 1.48; 95% CI, 1.14-1.93; P < 0.01). Median blood eosinophil levels for surgical patients were above levels for the cohort in all 18-month intervals March 11, 2000, through March 10, 2015, using 51,163 measurements representing 97,733 person-years of observation. Increasing age, increasing IL-17A, and low IgA in serum from 2001 to 2002 predicted blood eosinophil concentration in surgical patients but not in control subjects (R(2) = 0.26, P < 0.0001; vs. R(2) = 0.008, P = 0.56). CONCLUSIONS Increasing blood eosinophil concentration predicts surgical intervention for chronic rhinosinusitis, particularly in those with intense acute and prolonged exposure to airborne irritants. WTC-exposed Fire Department of New York firefighters who underwent irritant-associated sinus surgery are immunologically different from the cohort. Surgical patients have a higher blood eosinophil levels that is associated with mediators of mucosal immunity.

Comparison of fast-setting calcium phosphate bone cement and fat autograft in a rabbit model of frontal sinus obliteration.

Background Traditionally, chronic obstruction of the frontal recess is managed by frontal sinus obliteration (FSO). This often requires the harvest of abdominal fat as a filler with all of its associated morbidity. In this study, we investigate the efficacy of calcium phosphate bone cement (Craniofacial Repair System [CRS]) as a material for FSO. Methods Eighteen New Zealand white rabbits were divided into three groups and carried out to two time periods. Six rabbits underwent FSO with fat autograft (control group) and 12 rabbits underwent FSO with CRS (study groups 1 and 2, respectively). At 52 weeks, six control and six study rabbits were killed. The remaining six rabbits were killed at 78 weeks. All specimens underwent radiological evaluation with spiral computed tomography (CT) followed by gross inspection. Histological evaluation was then performed to assess bony growth and to evaluate the interface of the sinus wall with the obliterative material. Results Sinuses obliterated with CRS showed complete obliteration radiographically. This was apparent at 52 weeks and remained static at 78 weeks. Histological analysis indicated persistent obliteration of the sinus cavity from 52 to 78 weeks and signs of osteoinduction. There were no complications observed as a result of the operative procedure or the materials used. Conclusion CRS is an alternative to fat autograft for FSO in this noninfected animal model. Further studies are needed to evaluate its long-term efficacy as well as its behavior in chronically infected sinuses.

Frontorbital Fibrous Dysplasia Resection and Reconstruction With Custom Polyetherlatone Alloplast.

AbstractFibrous dysplasia (FD) is a benign, pathological development of bone. Craniofacial bones are the most commonly involved and can potentially cause visual disturbance, proptosis, orbital dystopia, and facial deformity. This case involves a 13-year-old girl with significant proptosis (20 mm left, 17.5 mm right) and downward displacement of the left globe (1.5 mm) due to fibrous dysplasia. Reconstruction was performed with computed tomography-derived and 3D printed custom polyetheretherketone (PEEK) implantation. PEEK is a nonabsorbable, nonporous thermoplastic polymer notable for its ability to be modified intraoperatively and ideal imaging properties postoperatively. Never, to our knowledge, has PEEK been used for primary reconstruction of the frontal orbital region in fibrous dysplasia in a child. The lesion was successfully repaired with excellent aesthetic and no apparent damage to neurovascular or ocular structures.