Philip G. Chen

Clinical Significance of Middle Turbinate Lateralization After Endoscopic Sinus Surgery

To investigate the clinical significance of middle turbinate lateralization (MTL) occurrence postendoscopic sinus surgery (ESS) for chronic rhinosinusitis, namely, association with postoperative symptoms and eventual need for undergoing revision surgery.

Mucosal remodeling and reversibility in chronic rhinosinusitis.

Purpose of reviewEvidence suggests that some structural changes caused by mucosal remodeling may be primarily irreversible, which theoretically challenges the current management model of chronic rhinosinusitis (CRS). The relationship between inflammation and remodeling in the mucosa remains complex, yet better understanding of involved pathways holds potential clinical implications. This article reviews the controversies as well as current applications from the literature. Recent findingsFirst, the relationship between inflammation and remodeling is a complex one involving multiple pathways, with evidence suggesting that remodeling is not a simple fibrotic end-stage process secondary to long-standing inflammation. Second, anti-inflammatory approaches alone are probably not successful in reversing changes such as collagen deposition, indicating that early treatment might be crucial for preventing disease progression. Third, a dysfunctional sinus remains a pure clinical/surgical phenomenon with lack of histological characterization. Fourth, maximal/extensive surgical techniques are advocated for patients with severe disease or dysfunctional sinuses. SummaryReversibility of remodeling holds implications for the management of CRS. Although clinical applications (both medical and surgical) exist, further research is required for solidifying current evidence as well as exploring new avenues for therapy.

Etiology of Nasal Polyps in Cystic Fibrosis: Not a Unimodal Disease

Objectives: The objective was to determine whether the polyp subtypes observed in cystic fibrosis (CF)–related sinusitis were similar to those observed in non–CF-related sinusitis. Methods: Polyp and mucus samples were collected from CF patients who presented for sinus surgery. The polyps underwent histologic and cytochemical evaluation for the presence of lymphocyte cell populations and their respective cytokine markers. The mucus samples were evaluated for DNA content. Results: Of the polyps, 42% had an eosinophilic infiltrate, of which 80% had an additional mixed neutrophilic infiltrate. Of the remaining polyp samples, 42% did not have a granulocytic infiltrate, consistent with non-eosinophilic polyps. All samples had CD138-positive plasma cells. The mucus samples from the patients with CF showed higher extracellular DNA concentrations than did the mucus samples from patients with non-CF sinus disease. Conclusions: Cystic fibrosis–related polyps demonstrated an eosinophil-based dichotomy similar to that of idiopathic non–CF-related polyps. Many also demonstrated neutrophilic infiltrate, indicating that chronic mucus stasis and infection complicate the disease. Agents capable of reducing extracellular DNA may help manage sinusitis in CF patients.

Fabrication and validation of a low-cost, medium-fidelity silicone injection molded endoscopic sinus surgery simulation model.

Develop a low‐cost, medium‐fidelity model for education in endoscopic sinus surgery techniques. Establish face and content validity of the model based on the feedback of otolaryngology faculty including fellowship‐trained rhinologists.

A golden experience: Fifty years of experience managing the frontal sinus

The frontal sinus is one of the most anatomically complex and inaccessible of the paranasal sinuses. As a result, surgeons have continually tried to improve surgical management of the frontal sinus. The senior author (c.w.g.) shares 50 years of experience managing the frontal sinus.

Incidence of middle turbinate lateralization after axillary flap approach to the frontal recess.

The axillary flap approach (AFA) to the frontal recess improves visualization and clearance while minimizing use of angled endoscopes. However, some argue that it destabilizes the middle turbinate (MT) and increases risk of MT lateralization (MTL). We aimed to establish rates of MTL after AFA, as well as to determine whether other surgical or disease factors affect lateralization.

Local class switching in nonallergic rhinitis.

Purpose of reviewPatients with seasonal and/or persistent symptoms consistent with rhinitis but negative systemic testing for atopy can be diagnostically challenging. It has been postulated that such idiopathic or nonallergic rhinitis may be due to localized class switching and production of IgE in the nasal mucosa, a process which has been termed entopy by some authors. This review analyzes the available data to describe the current understanding of this process as it relates to nonallergic rhinitis. Recent findingsRecent findings have demonstrated local IgE production in the nasal mucosa of patients who are otherwise negative on skin prick, intradermal, or serum testing for atopy. Comparable studies on nonatopic asthmatics have demonstrated evidence of local IgE class switching in lung respiratory mucosa. However, local class switching has only been unambiguously demonstrated in rhinitis patients when atopy is otherwise confirmed by routine testing. SummaryThere is significant evidence to indicate that local class switching in nonallergic rhinitis is possible; however, this has not been definitively proven. The question is raised as to whether local class switching can be demonstrated in nonallergic rhinitis and whether that class switching can be determined to be a specific affinity matured response. If present, a local IgE-mediated process is likely to define a cohort of nonallergic rhinitis more likely to respond to allergy-targeted therapies.

Teaching frontal sinus anatomy using the frontal sinus masterclass 3- D conceptualization model: Instructional Frontal Sinus Anatomy Course

Frontal sinus anatomy is complex and often is a difficult subject to both teach and learn. The traditional surgical dogma of “see one, do one, teach one” is impractical and dangerous in the frontal sinus. Based on the building block three‐dimensional conceptualization module, the Frontal Sinus Masterclass (FSMC) was created to teach this anatomy.

Sinus penetration of saline solution irrigation and atomizer in a cadaveric polyp and allergic fungal sinusitis model.

Allergic fungal sinusitis (AFS) is a stubborn disease requiring surgical and medical management. Delivery of topical medication is paramount in these patients, but the most difficult to accomplish. We investigated heavy irrigation (nasal douche) and atomized medication delivery potential in a cadaveric sinus model of polypoid AFS disease. Three disease models were created: a control that involved unoperated sinuses and no simulated disease; an unoperated AFS with type II polyposis mode; and an operated model with recurrent allergic fungal sinusitis with type II polyposis. The maxillary sinus showed the best irrigation and overall the heavy irrigator was more efficient than the atomizer.

Failure pressures of three rhinologic dural repairs in a porcine ex vivo model

The objective of this work was to determine the failure pressures of 3 commonly performed repair techniques of 5‐mm dural defects in a controlled setting.