Michele Cassano

Diagnosis and treatment of isolated sphenoid sinus disease: a review of 109 cases

Conclusion. Endoscopic transethmoidal sphenoidotomy performed mainly in the early stages of the pathology and by expert hands is [WX1]very effective in treating isolated sphenoid sinus disease. Objective. This study aimed to investigate the causes of isolated sphenoid sinus disease identified in 109 patients and report on the most appropriate diagnostic and therapeutic patterns for an earlier diagnosis and a successful treatment of the disease. Subjects and methods. A total of 109 subjects with various isolated sphenoid pathologies were first examined by general objective examination, nasal sinus endoscopy, CT scan of paranasal sinuses, and in some cases with MRI. Then, they underwent medical and/or surgical treatment. Results. Nineteen patients (17.43%) had isolated sphenoiditis, 6 (5.5%) fungal sinusitis, 30 (27.52%) mucocele, 6 (5.5%) fibrous dysplasia, 6 (5.5%) meningoencephalocele, 5 (4.58%) inverted papilloma, 4 (3.66%) epidermoid carcinoma, 10 (9.17%) liquor fistula, 1 (0.9%) rhabdomyosarcoma, 1 (0.9%)chordoma, and 1 (0.9%) had carotid pseudoaneurysm. Evidence of definitive diagnosis by endoscopy was obtained in less than half of the cases. CT scan, however, sometimes in combination with MRI, determined the pathology in all the cases. A follow-up of at least 4 years post-surgery showed good results in all the patients who underwent endoscopic transethmoidal sphenoidotomy.

Visual analog scale (VAS) and nasal obstruction in persistent allergic rhinitis

OBJECTIVE: Nasal airflow resistance, as measured by rhinomanometry, is frequently impaired in allergic rhinitis (AR). However, rhinomanometry is scarcely available. The aim of this study was to verify the suitability of the use of visual analog scales (VAS) as a surrogate for rhinomanometry in quantifying nasal obstruction in patients with persistent allergic rhinitis. STUDY DESIGN: Prospective study on patients with allergic rhinitis. SETTING: ENT clinic. SUBJECTS AND METHODS: Fifty patients (27 males, mean age 23 years, SD 2.24) were studied. VAS for nasal obstruction and other AR symptoms and rhinomanometry were performed in all patients. RESULTS: A significant, very strong correlation has been observed between VAS for nasal obstruction and nasal airflow resistance (Spearman r = 0.879, P < 0.001). Moreover, a significant correlation exists between VAS for rhinorrhea and resistance (Spearman r = 0.313, P = 0.027). CONCLUSION: The use of VAS for assessing the nasal obstruction appears clinically relevant in that it allows, with good reliability, the quantification of this symptom in the absence of rhinomanometry.

Endoscopic treatment of cerebrospinal fluid leaks with the use of lower turbinate grafts: a retrospective review of 125 cases.

BACKGROUNDnEndoscopic transnasal approaches to the skull base have revolutionized the treatment of cerebrospinal fluid (CSF) fistulae, making repair less invasive and more effective compared with craniotomy or extracranial techniques.nnnAIMnThis study evaluated, retrospectively, the results of endoscopic repair of dural defects with the use of mucoperiostal grafts taken from the lower turbinate.nnnMATERIALS AND METHODSnBetween January 1997 and January 2007, 125 cases of anterior skull base CSF fistulae were treated endoscopically at the Instituto Felippu de Otorrinolaringologia, Sao Paolo, Brazil, and at the Department of Otolaryngology of the University Hospital Ospedali Riuniti, Foggia, Italy. Fistula closure was achieved by overlay apposition of a lower turbinate mucoperiostal graft fixated with fibrin glue and Surgicell.nnnRESULTSnThe etiology of the fistula was accidental trauma in 41 cases, iatrogenic trauma in 29, skull base tumour in 12, and spontaneous in 43. The site of the defect was the sphenoid sinus in 43 patients, the cribriform plate in 42, the anterior ethmoid roof in 21, the posterior ethmoid roof in 17, and the posterior wall of the frontal sinus in 2. The success rate at first attempt was 94.4%; the 7 cases of postoperative recurrent CSF leakage involved patients presenting with spontaneous fistula and elevated intracranial pressure; 5 of these had a body-mass index > 30 and 3 suffered from diabetes mellitus.nnnDISCUSSION AND CONCLUSIONnIn our hands, the success rate of endoscopic fistula repair was high, even in defects larger than 2 cm. Success rates may be further improved with accurate diagnosis of elevated intracranial pressure, a contributing factor to failure of spontaneous fistula repair.

Nasal cytology: description of a hyperchromatic supranuclear stria as a possible marker for the anatomical and functional integrity of the ciliated cell.

Background The aim of this study was to describe a particular intracellular hyperchromatic formation located over the nucleus of normal nasal ciliated cells. This finding, never described in literature, very rarely occurs in pathological conditions. Methods A nasal cytological test and mucociliary transport test were performed in a group of 24 subjects with rhinologic diseases and in a control group of 10 healthy subjects. Results The “hyperchromatic supranuclear stria” (SNS) was observed in a high percentage of normal cells (90.3%); SNS was present in very few pathological subjects (in only 6.26% of pathologic cells). Conclusion We interpreted SNS as a specific marker for the anatomic and functional integrity of the ciliated cell. Therefore, the absence of SNS is considered an abnormal finding in the nasal mucosa and therefore could be useful as a “prognostic sign” of the disorders themselves and as an indication of the “therapeutic efficacy” of pharmacologic treatments, both topical and systemic.

Endoscopic intraoperative control of epistaxis in nasal surgery

OBJECTIVEnEpistaxis represents a dangerous post-operative complication of nasal surgery. The advances of endoscopic procedures have also brought along the possibility of a surgical solution of nasal bleeding. These procedures include endoscopic cautery of the bleeding points, and more difficult techniques of endoscopic ligation of the sphenopalatine artery or the anterior ethmoidal artery. These surgical methods permit avoiding nasal packing, a very annoying procedure for the patient. This study aims to evaluate the advantages of this approach at the end of a nasal surgery to prevent routine nasal packing.nnnMETHODn133 subjects were operated on by the same surgeon in the Otorhinolaringology Department of University of Foggia (Italy) from March 2006 to March 2007. 17 (12.8%) patients were submitted to septoplasty, 42 (31.5%) to turbinoplasty (in 22 accompanied by septoplasty) and 74 (55.6%) to endoscopic sinus surgery (ESS) for nasal polyposis or nasal tumors.nnnRESULTSnOnly 16 cases (12%) underwent nasal packing, while in the remaining 117 (88%) endoscopic control of bleeding permitted avoiding packing. In 53 (39.8%) patients only an endoscopic cauterization of bleeding points was performed; in 29 (21.8%) cases a sphenopalatine artery ligation was necessary. Only 2 subjects (1.5%) underwent anterior ethmoidal artery ligation. In the remaining 34 (25.5%) patients no procedure was necessary, due to the apparently scarce bleeding in the endoscopic vision at the end of surgery. In this group of non-packed patients, only 8 (6.8%) needed a post-operative tamponade while in the group of packed patients, 2 (12.5%) cases had a re-bleeding and a revisional surgery was necessary.nnnCONCLUSIONnIntra-operative precautional packing is therefore not justified during nasal surgery because of the small percentage of post-operative epistaxis. Intra-operative control of bleeding allowed nasal packing to be avoided in a large percentage of cases.

Retraction pockets of pars tensa in pediatric patients: clinical evolution and treatment.

OBJECTIVEnTo assess outcome in pediatric patients after treatment for retraction pockets of pars tensa in relation to retraction grade, site, occurrence of complications, and patient age.nnnMETHODSnOutcomes in 45 ears of 37 children medically or surgically treated for retraction pockets were compared to a control group of 40 untreated children over a follow-up period of at least 24 months. Grade I and II retractions were treated with medical therapy or ventilation tube insertion; in III or IV grade retractions, excision and tympanic reinforcement with cartilage grafting and in some cases ossiculoplasty were performed.nnnRESULTSnMedical treatment or ventilation tube insertion resolved grade I and II retractions in 94% of cases. In grade III or IV retractions the anatomic success rate was 75.8%. Normal hearing (air-bone gap <10 dB) was restored in 31 (68.8%) cases. Surgical failures and complications (recurrence, tympanic membrane perforation, progression to cholesteatoma) were higher in posterior retractions. In the control group, only 35% of retractions healed spontaneously; in the remaining cases the condition progressed to more serious retractions or complications.nnnCONCLUSIONnA wait and see approach or conservative therapy is indicated only in mild-to-moderate retraction pockets owing to their benign prognosis. Pocket excision and tympanic reinforcement are absolutely indicated in advanced retractions with complications and/or bilateral conductive hearing loss to avert progression to more serious pathologies.

Restoration of nasal cytology after endoscopic turbinoplasty versus laser-assisted turbinoplasty.

Background Insult from surgical trauma leads to a degeneration of the nasal epithelium, resulting in morphological–volumetric changes involving the entire cell or a specific cell component. Alterations in normal nasal mucosa were assessed by nasal cytology and other functional tests after either endoscopic turbinoplasty or laser-assisted turbinoplasty for reducing inferior turbinate enlargement. Methods A total of 150 patients with chronic nasal obstruction due to inferior turbinate hypertrophy were randomly assigned to undergo laser-assisted turbinoplasty or endoscopic turbinoplasty. Preoperative and postoperative assessment at 1 and 3 months follow-up included active anterior rhinomanometry, measurement of mucociliary transport time (MCTt), and nasal cytology to determine whether improved nasal breathing was accompanied by a restoration of preoperative nasal cytology and MCTt. One year after the operation, nasal cytology was repeated to definitively evaluate the presence of surgery-related cytological damage. Results At both postoperative visits, nasal resistance had decreased similarly in both treatment groups; mean MCTt was significantly shorter in the endoscopic turbinoplasty-treated group (p < 0.05); at both visits, the number of altered ciliated cells had increased in the laser-assisted turbinoplasty-treated group but decreased in the endoscopic turbinoplasty-treated group, which, unlike the laser-assisted turbinoplasty-treated group, was also noted to have progressed toward a significant improvement in the goblet-to-ciliated cell ratio (p < 0.01). Conclusion When compared with laser-assisted turbinoplasty, endoscopic turbinoplasty is a conservative technique for inferior turbinate reduction that allows better restoration of preoperative nasal cytology and shorter MCTt.

Acoustic pharyngometry: clinical and instrumental correlations in sleep disorders

UNLABELLEDnAcoustic Pharyngometry is a modern diagnostic method based on physical principle of acoustic reflection. It is useful for volume analysis of oro-pharyngo-laryngeal spaces.nnnAIMnTo evaluate variations of pharyngometric parameters in patients with sleep disorders and to establish a correlation between morpho-volumetric variations of oro-pharyngo-laryngeal spaces and the presence and severity of disease.nnnSTUDY DESIGNna clinical and experimental study.nnnMATERIAL AND METHODn110 patients, of which 70 with sleep disorders and 40 healthy patients as a control group, were analysed between June 2004 and June 2005. All patients underwent acoustic pharyngometry to evaluate the mouth and hypopharynx based on an explanatory chart.nnnRESULTSnA significant difference in parameters was observed between sleep disorder patients and the control group, especially in the amplitude of the I wave (significantly lower in patients with macroglossia), the extension of the O-F segment, and the amplitude of the O-F segment and hypopharyngeal area.nnnCONCLUSIONnAlthough not a standardized test, acoustic pharyngometry was proved to be a useful method both in the diagnosis and severity of obstructive sleep apnea, and in post-operative monitoring of upper airway surgery in patients with sleep disorders.

A faringometria acústica: correlações clínico-instrumentais nos distúrbios do sono

Acoustic Pharyngometry is a modern diagnostic method based on physical principle of acoustic reflection. It is useful for volume analysis of oro-pharyngo-laryngeal spaces. AIM: To evaluate variations of pharyngometric parameters in patients with sleep disorders and to establish a correlation between morpho-volumetric variations of oro-pharyngo-laryngeal spaces and the presence and severity of disease. STUDY DESIGN: a clinical and experimental study. MATERIAL AND METHOD: 110 patients, of which 70 with sleep disorders and 40 healthy patients as a control group, were analysed between June 2004 and June 2005. All patients underwent acoustic pharyngometry to evaluate the mouth and hypopharynx based on an explanatory chart. RESULTS: A significant difference in parameters was observed between sleep disorder patients and the control group, especially in the amplitude of the I wave (significantly lower in patients with macroglossia), the extension of the O-F segment, and the amplitude of the O-F segment and hypopharyngeal area. CONCLUSION: Although not a standardized test, acoustic pharyngometry was proved to be a useful method both in the diagnosis and severity of obstructive sleep apnea, and in post-operative monitoring of upper airway surgery in patients with sleep disorders.

Cytologic alterations in nasal mucosa after sphenopalatine artery ligation in patients with vasomotor rhinitis.

Background Vasomotor rhinitis (VR) seems to be related to an imbalance between cholinergic and adrenergic activity in the autonomic nervous system. The nerve fibers of the sympathetic and parasympathetic nervous systems reach the nose through the posterior nasal nerve, which, after crossing the sphenopalatine foramen, distributes to the mucosa following the branches of the sphenopalatine vessels. This study was designed to evaluate the effect of sphenopalatine artery ligation on nasal function and nasal cytology in patients with VR. Methods Thirty patients with VR and bilateral inferior turbinate hypertrophy (ITH) were randomly assigned to receive endoscopic inferior turbinoplasty either with or without sphenopalatine artery ligation. Pre- (baseline) and postsurgical (1-year follow-up) assessment included fiber endoscopy, active anterior rhinomanometry, measurement of mucociliary transport time (MTt), and nasal cytology examination. Results At 1-year follow-up there was a statistically significant improvement in nasal resistances in both groups but not on intergroup comparison; MTt significantly decreased in both groups (p < 0.01) and was significantly better (p < 0.05) in the group that had undergone sphenopalatine artery ligation. Among the patients in this group, significantly fewer were found to have altered ciliated cells (p < 0.005) or a hyperchromatic supranuclear stria (p < 0.005) on nasal cytology; the differences were statistically significant also on in intergroup comparison (p < 0.005 and p < 0.001, respectively). Conclusion In patients with vasomotor rhinopathy and ITH, improvement in symptoms, nasal resistance, ciliated cell trophism, and MTt was observed after sphenopalatine artery ligation.