Mohamad R. Chaaban

Epidemiology and differential diagnosis of nasal polyps.

Background Chronic rhinosinusitis (CRS) is one of the most common chronic medical conditions, with a significant impact on patient quality of life. CRS is broadly classified into two groups: CRS with nasal polyposis (CRSwNP) and CRS without NP (CRSsNP). Clinically, the major subtypes of CRSwNP may be divided into eosinophilic chronic rhinosinusitis (e.g., allergic fungal rhinosinusitis and aspirin-exacerbated respiratory disease [AERD]) and nasal polyps associated with neutrophilic inflammation (e.g., cystic fibrosis [CF]). CF is characterized by mutation of the gene encoding the CF transmembrane conductance regulator. Functional endoscopic sinus surgery is usually required for most NP patients with increased frequency in patients with AERD. This study provides a review of the epidemiology and major classification of CRSwNP. Methods A review was performed of the literature regarding different subtypes of CRSwNP. Results Many definitions of CRSwNP exist and estimates of prevalence vary. Conclusion CRSwNP is a clinical syndrome with a heterogeneous inflammatory profile. Of the subtypes associated with eosinophilic inflammation, AERD remains the most recalcitrant to medical and surgical therapeutic interventions.

Spontaneous cerebrospinal fluid leak repair: A five‐year prospective evaluation

Mounting evidence indicates the majority of spontaneous cerebrospinal fluid (CSF) leaks are associated with intracranial hypertension. The objectives of the current study were to assess outcomes regarding spontaneous CSF leaks focusing on premorbid factors, surgical technique, and management of intracranial pressure.

Cystic Fibrosis Chronic Rhinosinusitis: A Comprehensive Review:

Background Advances in the care of patients with cystic fibrosis (CF) have improved pulmonary outcomes and survival. In addition, rapid developments regarding the underlying genetic and molecular basis of the disease have led to numerous novel targets for treatment. However, clinical and basic scientific research focusing on therapeutic strategies for CF-associated chronic rhinosinusitis (CRS) lags behind the evidence-based approaches currently used for pulmonary disease. Methods This review evaluates the available literature and provides an update concerning the pathophysiology, current treatment approaches, and future pharmaceutical tactics in the management of CRS in patients with CF. Results Optimal medical and surgical strategies for CF CRS are lacking because of a dearth of well-performed clinical trials. Medical and surgical interventions are supported primarily by level 2 or 3 evidence and are aimed at improving clearance of mucus, infection, and inflammation. A number of novel therapeutics that target the basic defect in the cystic fibrosis transmembrane conductance regulator channel are currently under investigation. Ivacaftor, a corrector of the G551D mutation, was recently approved by the Food and Drug Administration. However, sinonasal outcomes using this and other novel drugs are pending. Conclusion CRS is a lifelong disease in CF patients that can lead to substantial morbidity and decreased quality of life. A multidisciplinary approach will be necessary to develop consistent and evidence-based treatment paradigms.

Acetazolamide for high intracranial pressure cerebrospinal fluid leaks.

Acetazolamide has become a standard treatment for cerebrospinal fluid (CSF) leaks associated with intracranial hypertension. The purpose of the current study was to evaluate the effectiveness of acetazolamide at decreasing elevated CSF pressure in this patient population.

Porcine small intestine submucosal graft for endoscopic skull base reconstruction

Skull base defects and encephaloceles of the sinus and nasal cavities are routinely repaired endoscopically using a variety of materials including bone, cartilage, fascia, acellular dermal allografts, and xenografts, with high success rates. However, there is a paucity of data regarding the use of porcine small intestine submucosal (SIS) grafts for endoscopic dural repair. The purpose of the current study was to review outcomes using SIS grafts in the endoscopic reconstruction of skull base defects.

Assessing nasal Air flow: Options and utility

This article focuses on the tools that are available to assess nasal airflow, their utility in clinical practice, and comparison between them. Assessment of the nasal airway traditionally relied on history and physical examination only. Recently, tools have been developed that aid the physician in completing an assessment by measurement of parameters that are directly or indirectly related to airflow. Many physiologic and pathologic conditions can influence the amount of airflow or nasal airway resistance. These conditions can include normal changes, such as the nasal cycle, or pathology, such as septal deviations, turbinate hypertrophy, tumors, synechiae, nasal congestion or obstruction, allergies, nonallergic rhinitis, and sinonasal polyposis. Objective measures can be used to assist the clinician to diagnose and treat nasal complaints and also for objective quantification for research.

Simultaneous pericranial and nasoseptal flap reconstruction of anterior skull base defects following endoscopic-assisted craniofacial resection

presented at the Annual AAOHNS meeting in Washington DC, 2012. Dr. Bradford Woodworth is a consultant for Gyrus and Arthrocare. The authors have no other funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Bradford A. Woodworth, MD, University of Alabama at Birmingham, Otolaryngology–Head and Neck Surgery, BDB 563, 1530 3rd Ave S, Birmingham, AL 35294. E-mail: bwoodwo@hotmail.com DOI: 10.1002/lary.24071 Laryngoscope 123: October 2013 Chaaban et al.: Simultaneous Pericranial and Nasoseptal Flap

Transnasal Endoscopic Repair of Posterior Table Fractures

Objectives/Hypothesis Conventional treatment of frontal sinus posterior table fractures has included osteoplastic flap or cranialization procedures despite considerable advances in endoscopic technique and experience. The objective of the current study was to evaluate outcomes of frontal sinus fractures involving the posterior table managed using endoscopic approaches. Study Design Prospective cohort. Setting Tertiary care, academic university hospital. Methods Prospective evaluation of patients with posterior table fractures was performed. Data were collected regarding demographics, etiology, technique, operative site, length involving the posterior table, size of the skull base defect, complications, and clinical follow-up. Results Thirteen patients (average age 37 years) with posterior table fractures were treated using endoscopic techniques from 2008 to 2012. Mean follow-up time was 68 weeks (range, 2-206 weeks). Patients were primarily managed using Draf IIb frontal sinusotomies with 1 individual requiring a concomitant trephine. A Draf III procedure was performed in 1 patient. Average fracture defect (length vs width) was 13 × 4.5 mm, and average length involving the posterior table was 9.7 mm (1-30 mm). Skull base defects were covered with a septal flap and/or free tissue grafts. Although 1 individual required a revision frontal sinusotomy and follow-up was short in several patients, all sinuses remained patent on last clinical examination. Conclusion Management of frontal sinus posterior table fractures using minimally invasive endoscopic techniques provides excellent outcomes in selected cases. Fractures of up to 30 mm in length were adequately managed in this series and indicate this approach can be a viable alternative in the treatment of these fractures.

Blood Loss During Endoscopic Sinus Surgery With Propofol or Sevoflurane: A Randomized Clinical Trial

IMPORTANCE Total intravenous anesthesia (TIVA) with propofol has been associated with reduced operative time, decreased perioperative risks, and decreased intraoperative blood loss compared with inhalational anesthesia (IA). During endoscopic sinus surgery (ESS), reduced bleeding from the mucosal surfaces could improve visualization of the anatomy and decrease the risk of serious complications. OBJECTIVE To compare blood loss during ESS between patients receiving TIVA with propofol and those receiving IA with sevoflurane. DESIGN, SETTING, AND PARTICIPANTS Prospective, randomized study of 33 patients undergoing ESS in an academic medical center. INTERVENTIONS Patients received either TIVA or IA. MAIN OUTCOMES AND MEASURES The primary outcome was rate of blood loss in milliliters per hour. The secondary outcomes included the quality of visibility measured by the surgeons numeric rating score, ease of anesthesia as measured by the anesthesiologists numeric rating score, and total blood loss. RESULTS The mean (SEM) blood loss per hour in the TIVA group was 78.5 (14) mL/h, and in the IA group it was 80.3 (17) mL/h (P = .93). A post hoc subgroup analysis found that in patients with a Lund-Mackay score of 12 or lower, the propofol TIVA group had a lower rate of blood loss compared with the sevoflurane IA group (mean blood loss, approximately 18 mL/h vs approximately 99 mL/h). The anesthesiologists numeric rating score was significantly higher (indicating greater ease of performance) in the IA group than in the TIVA group. There was no statistically significant difference in the surgical numeric rating score between the 2 groups. CONCLUSIONS AND RELEVANCE In this comparative study, our results did not show any difference in blood loss and surgical conditions between the TIVA and IA groups. Even further study is not likely to show a difference in blood loss between TIVA and IA during ESS.

Objective assessment of olfaction after transsphenoidal pituitary surgery.

Background Transnasal endoscopic pituitary surgery has proven to be a safe and effective method for removing pituitary tumors. Direct and angled endoscopy at the site of dissection provides excellent visualization without external incisions. However, olfactory loss has been documented after surgical approaches to the pituitary and is accompanied by a significant detriment to quality of life. Study Design A prospective cohort study. Methods Subjects 19 years and older who were undergoing transnasal endoscopic pituitary surgery were recruited for this study. The University of Pennsylvania Smell Identification Test (UPSIT) was administered preoperatively and then at 3–4 months. Data regarding demographics, reconstructive technique, and complications were recorded. The patients had skull-base reconstruction with a Medpore implant or a vascularized nasoseptal flap. Results and Discussion A total of 33 subjects were recruited, with 18 completing the study. The mean (SEM) age was 58.2 ± 2.4 years, with 12 females and 6 males. The majority of patients (89%) had nonfunctioning macroadenomas, and six individuals had reconstruction by using a vascularized nasoseptal flap. Matched mean (SEM) preoperative and postoperative UPSIT scores for this cohort were not significantly different (31.3 ± 0.4 versus 30.5 ± 0.5, respectively; p = 0.54). In addition, there was no significant difference between the mean preoperative and postoperative UPSIT scores of the patients who had nasoseptal flaps (29.4 ± 1.1 vs. 28.6 ± 1.3 respectively; p = 0.87). Conclusions In the current study, pre- and postoperative UPSIT scores were not significantly different in patients who underwent endoscopic transnasal pituitary surgery. The use of a nasoseptal flap also did not adversely affect postoperative UPSIT scores.