Nicolas Y. Busaba

Maxillary Sinus Mucoceles: Clinical Presentation and Long‐Term Results of Endoscopic Surgical Treatment

Objective: To describe the clinical presentation of maxillary sinus mucoceles, understand their pathogenesis, and determine the long‐term efficacy of the endoscopic surgical treatment.

Endoscopic Sinus Surgery for Inflammatory Maxillary Sinus Disease

Objective/Hypothesis The role of endoscopic sinus surgery for treating chronic maxillary sinusitis is well established. The purpose of the study is to determine the efficacy of endoscopic sinus surgery in the treatment of maxillary sinus inflammatory disease that includes mucoceles, retention cysts, and antrochoanal polyps.

Predictors of Prolonged Length of Stay After Major Elective Head and Neck Surgery

Objective/Hypothesis: Longer length of stay (LOS) after elective surgery is associated with an increased use of health care resources and higher costs. The objectives of this study were to determine the perioperative factors that predict a prolonged LOS after elective major head and neck operations and to test the hypothesis that factors related to process of care (intra‐ and postoperative) independently predict prolonged LOS after adjustment for preoperative patient characteristics.

Efficacy of Montelukast in the Treatment of Nasal Polyposis

Objectives: Twenty-four consecutive patients with symptomatic nasal polyposis and nonallergic or perennial rhinitis who were undergoing chronic nasal steroid therapy were prospectively evaluated for response to adjunctive oral montelukast sodium therapy. Methods: The patients were undergoing daily intranasal steroid sprays for a minimum of 6 months before being started on montelukast sodium 10 mg by mouth per day for 3 months while intranasal steroids were continued. The patients were given a validated symptom score survey at the start and end of therapy, with a lower score indicating fewer symptoms. The nasal polyps were submitted to biopsy before and after treatment to determine their degree of eosinophilia. Eosinophilia was graded in a blinded fashion by an independent pathologist on a scale of 0 to 3, with 3 being severe. Patients with seasonal allergies were excluded, and the studied patients were treated during the winter season to avoid confounding by potential seasonal allergic responses. Results: The patients tended to improve on montelukast therapy in terms of their symptom scores and polyp eosinophil counts. The symptoms improved in 17 patients (71%) and remained the same or worsened in 7 patients (29%). The symptom score for the group improved from a pretreatment value of 33.4 (SD, 7.73) to a posttreatment value of 23.3 (SD, 13.73; p < .001). In addition, the eosinophilia score improved from 2.3 (SD, 0.68) to 1.5 (SD, 0.82; p < .01). The improvement was most noticeable in the patients with perennial allergies. Conclusions: These results suggest that montelukast appears to be beneficial for some patients with nasal polyposis. Patients with perennial allergies and nasal polyposis seem more likely to respond to the treatment than those with nonallergic nasal polyposis.

Cigarette smoke combined with Toll-like receptor 3 signaling triggers exaggerated epithelial regulated upon activation, normal T-cell expressed and secreted/CCL5 expression in chronic rhinosinusitis

BACKGROUND Chronic rhinosinusitis (CRS) is characterized by persistent mucosal inflammation and frequent exacerbations. OBJECTIVE To determine whether innate epithelial responses to cigarette smoke or bacterial or viral pathogens may be abnormal in CRS leading to an inappropriate inflammatory response. METHODS Primary nasal epithelial cells (PNECs) were grown from middle turbinate biopsies of 9 healthy controls and 11 patients with CRS. After reaching 80% to 90% confluence, PNECs were exposed to medium or cigarette smoke extract (CSE) 5% (vol/vol) for 1 hour, washed, then stimulated with staphylococcal lipoteichoic acid, LPS, or double-stranded RNA (dsRNA). After 24 hours, gene expression was quantified by QRT-PCR. RESULTS At baseline, PNECs revealed elevated TNF-alpha and growth-related oncogene-alpha (a C-X-C chemokine)/CXCL1 (GRO-alpha) (4-fold increase, P = .02; and 16-fold increase, P = .004, respectively) in subjects with CRS compared with controls with normal levels of IL-1beta, IL-6, IL-8/CXCL8, human beta-defensin-2, monocyte chemoattractant protein 2/CCL8, monocyte chemoattractant protein 3/CCL7, and regulated upon activation, normal T-cell expressed and secreted (RANTES)/CCL5. Immunostaining of nasal biopsies, however, revealed comparable epithelial staining for TNF-alpha, GRO-alpha, and RANTES. There were no differences in mRNA induction by CSE, TNF-alpha, lipoteichoic acid, LPS, or dsRNA alone. The combination of CSE+dsRNA induced exaggerated RANTES (12,115-fold vs 1500-fold; P = .03) and human beta-defensin-2 (1120-fold vs 12.5-fold; P = .05) in subjects with CRS. No other genes were differentially induced. Furthermore, CSE+dsRNA induced normal levels of IFN-beta, IFN-lambda1, and IFN-lambda2/3 mRNA in subjects with CRS. CONCLUSION Cigarette smoke extract plus dsRNA induces exaggerated epithelial RANTES expression in patients with CRS. We propose that an analogous response to cigarette smoke plus viral infection may contribute to acute exacerbations and eosinophilic mucosal inflammation in CRS.

Laser-Doppler Measurements and Electrocochleography during Ischemia of the Guinea Pig Cochlea: Implications for Hearing Preservation in Acoustic Neuroma Surgery

Interruption of cochlear blood flow has been implicated as one of the causes of the sensorineural hearing loss that may occur during acoustic neuroma surgery. With the guinea pig as an animal model for cerebellopontine angle surgery, laser-Doppler measurements were used to estimate the cochlear blood flow changes caused by compression of the eighth nerve complex. With compression, the laser-Doppler measurements decreased abruptly; somewhat later, the electrocochleographic potentials declined. When compression was released, laser-Doppler measurements usually returned immediately, followed later by return of the electrical potentials. Some of these potentials, including the compound action potential of the auditory nerve, often became transiently larger than their precompression values. Interposing bone between the laser-Doppler probe and the otic capsule, so that the total bone thickness approximated the thickness of the human otic capsule, decreased the laser-Doppler measurement, but changes caused by compression were still apparent. Thus, although the human otic capsule is much thicker than the guinea pig capsule, it may still be possible to make laser-Doppler estimates of human cochlear blood flow. Laser-Doppler monitoring during acoustic neuroma surgery may be beneficial, because it could give earlier warning of ischemia than is currently available from electrocochleographic monitoring, thereby enabling earlier corrective action. Electrocochleography complements laser-Doppler measurements by indicating the physiologic state of the cochlea.

Ethmoid Mucocele as a Late Complication of Endoscopic Ethmoidectomy

OBJECTIVE Our goal was to describe ethmoid mucocele as a late complication of endoscopic ethmoidectomy. STUDY DESIGN This was a retrospective review of 14 patients who were diagnosed with ethmoid mucoceles after endoscopic ethmoidectomy. Reviewed data included patient demographics, indication for the original surgery, presenting symptoms, computed tomography results, surgical treatment, operative findings, and recurrence of disease. RESULTS The mucoceles were diagnosed 1 to 13 years after endoscopic ethmoidectomy. The most common presenting symptom was facial pressure or pain. Twelve patients had middle meatal adhesions. A round mass was seen by endoscopy in the ethmoid cavity in 5 patients. Nine mucoceles were located in the anterior ethmoid and 3 were located in the posterior ethmoid, and 2 involved both. The mucoceles were marsupialized via revision endoscopic ethmoidectomy in 12 patients, whereas 2 had both external and endoscopic approaches taken. CONCLUSION Ethmoid mucocele can form as a late complication of endoscopic ethmoidectomy. It is commonly associated with middle meatal adhesions.

Same-Day Discharge for Selected Patients Undergoing Combined Nasal and Palatal Surgery for Obstructive Sleep Apnea:

To determine the safety of same-day discharge for patients who undergo combined nasal and palatal surgery for obstructive sleep apnea syndrome, we undertook a retrospective review and analysis of 2 groups of patients (total, 86 patients) who underwent such surgery. The patients with obstructive sleep apnea syndrome who underwent combined nasal and palatal surgery were considered for same-day discharge if they fulfilled the following postoperative criteria: sustained O2 saturation of 94% or greater on room air while asleep, no history of cardiopulmonary disease or diabetes mellitus, adequate oral analgesia and oral intake, hemostasis, and normal vital signs. Twenty-three patients met these criteria and were assigned to group 1. The remaining 63 patients were admitted overnight for monitoring and were assigned to group 2. The data collected included patient demographics, respiratory disturbance index, lowest O2 saturation, body mass index, and postoperative complications. The mean age, respiratory disturbance index, lowest O2 saturation, and body mass index for group 1 were 45.9 years, 36 events per hour, 84.9%, and 28.7 kg/m2, respectively. For group 2, the results were 48 years, 36.5 events per hour, 82%, and 32.5 kg/m2. There were no postoperative complications in group 1, and 3 in group 2. There were no incidents of airway compromise or cardiopulmonary events in the immediate postoperative period in either group. There were no readmissions for either group. We conclude that same-day discharge for patients who have undergone combined nasal and palatal surgery for obstructive sleep apnea syndrome is relatively safe in selected cases in which significant comorbid diseases are not present. These selected cases would have constituted a minority of the patients studied.

Bacteriology of Nontraumatic Maxillary Sinus Mucoceles Versus Chronic Sinusitis

Objective To compare the bacteriology of maxillary sinus mucoceles to chronic sinusitis and understand the pathogenesis of nontraumatic maxillary sinus mucoceles (NTMSM).

Clinical Presentation and Management of Labyrinthine Fistula Caused by Chronic Otitis Media

To describe the clinical presentation and surgical management of patients with chronic otitis media complicated by labyrinthine fistula and to determine clinical indicators that predict postoperative hearing outcome, I performed a retrospective analysis at an academic tertiary care center. Thirty-four patients with labyrinthine fistula as a complication of chronic otitis media, documented at mastoidectomy, underwent postoperative audiometry. The median age was 50 years, and the duration of otologic symptoms ranged from 2 months to more than 40 years. On presentation, 3 patients had anacusis in the affected ear, while in the others, the pure tone average for bone conduction at the 0.5-, 1-, 2-, and 4-kHz frequencies was 34 dB hearing level. Nineteen patients (56%) complained of dizziness on presentation. The fistula test was positive in 14 of 28 patients (50%). The fistula was detected radiologically in 10 of 24 patients (42%). Cholesteatoma was present in 33 of 34 patients (97%). The lateral semicircular canal was the most common site of labyrinthine fistula. The cholesteatoma matrix was completely removed in 29 of 33 cases and exteriorized in the remaining 4. Of the 31 patients with measurable hearing preoperatively, anacusis occurred in 8 (26%). In 6 of these, the preoperative pure tone average for bone conduction was greater than 50 dB hearing level, and cholesteatoma matrix and granulation tissue invading the membranous labyrinth were found at surgery. I concluded that in chronic otitis media, labyrinthine fistulas occurred almost exclusively in the presence of a cholesteatoma. Postoperative hearing outcome correlated with the size of the fistula and the presence of granulation tissue invading the labyrinth, which could be predicted by the preoperative audiometry.