Rakesh K. Chandra

Long-term effects of FloSeal packing after endoscopic sinus surgery.

Background A previous study by our group showed increased adhesions and granulation tissue in ethmoid cavities packed with FloSeal (FS) compared with those packed with thrombin-soaked gelatin foam after endoscopic sinus surgery (ESS). That study included 20 patients whose cavities were graded 6–8 weeks postoperatively. The goal of this study was to report long-term follow-up on this cohort. Methods At least 1 year follow-up was available in 18/20 patients. The number of office procedures required to lyse adhesions during the follow-up period was tabulated also. Pathology was available from one patient who underwent lysis of adhesions on an FS side. The histopathological findings are presented. Results The mean follow-up period was 21.4 (±2.3) months, and none of the 18 patients required revision ESS during this interval. The overall incidence of adhesions (p = 0.013) and the number requiring lysis of adhesions (p = 0.046) were both greater in the FS group. During the interval between previous study evaluation (6–8 weeks postop) and last follow-up, five FS sides required a total of seven procedures to lyse adhesions. Silent adhesions were observed in an additional five FS sides. Although asymptomatic adhesions were observed in two thrombin-soaked gelatin sides at last examination, none underwent lysis. Biopsy of an adhesion from a patient packed with FS 25 months earlier revealed incorporated foreign material. Conclusion FS appears to be associated with scar tissue formation and may be incorporated into recovering mucosa. Use of FS may increase the degree of postoperative care required after ESS.

Intracranial Complications of Pediatric Sinusitis

OBJECTIVE: To study intracranial extension of pediatric sinusitis, an infrequent but potentially fatal complication. STUDY DESIGN AND SETTING: Ten-year retrospective review at a tertiary childrens hospital identified 21 cases of intracranial complications of sinusitis. RESULTS: Thirteen males and eight females with mean age of 13.3 years were identified. Overall 18 of 21 (81%) exhibited abscess formation, most commonly epidural. Only 3 of 21 (14%) had meningitis alone. All but 4 patients were managed surgically, requiring craniotomy in 13 of 21 (61.9%) and endoscopic sinus surgery (ESS) in 10 of 21 (48%). Seven patients (33%) required multiple operations during admission. Nineteen patients (90%) had a total of 30 organisms cultured. Oral flora was observed in 12 of 21 (57%). Polymicrobial infections, seen in 9 of 21 (43%), were significantly associated with the need for craniotomy (P = 0.02). Mean hospital stay was 15 days, and mean length of IV antibiotic was 5 weeks. CONCLUSIONS: Intracranial complications of pediatric sinusitis often require craniotomy. Oral flora and polymicrobial infections were prominent in this series. EBM rating: C-4

Advantages and disadvantages of topical packing in endoscopic sinus surgery.

Purpose of reviewPractices regarding the use of nasal packing after endoscopic sinus surgery vary widely among surgeons. Recent trends have included the use of various topical, absorbable agents. The purpose of this review is to clarify the rationale for the selection of these products. Recent findingsAlthough many of these materials have proven to be effective as hemostats, data are conflicting regarding their effect on mucosal healing. Studies in both humans and animals have raised the concern that these agents may be associated with increased scar tissue formation. SummaryThe exact roles for the various available materials are yet to be established. The primary advantage is that they do not require removal, which may improve patient comfort. Currently, however, it does not appear that the use of topical absorbable packing is a substitute for routine postoperative debridement.

A gelatin-thrombin matrix for hemostasis after endoscopic sinus surgery☆

PURPOSEnAdequate hemostasis is necessary after endoscopic sinus surgery. This study evaluated the clinical performance of Surgiflo hemostatic matrix (Johnson&Johnson Wound Management, a division of Ethicon Inc, Somerville, NJ) with Thrombin-JMI (distributed by Jones Pharma Inc, Bristol, VA, a wholly owned subsidiary of King Pharmaceuticals, Bristol, TN) in achieving hemostasis in patients undergoing endoscopic sinus surgery. Surgiflo hemostatic matrix is a sterile, absorbable porcine gelatin intended to aid with hemostasis when applied to a bleeding surface.nnnMATERIALS AND METHODSnThis multicenter, prospective, single-arm study evaluated the success in achieving hemostasis within 10 minutes of product application in patients undergoing elective primary or revision endoscopic sinus surgery for chronic sinusitis with a bleeding surface requiring hemostasis. Patient satisfaction and postoperative healing were also evaluated.nnnRESULTSnThirty patients were enrolled, including 17 males and 13 females (average age, 48.2 +/- 15.1 years), with 54 operated sides. Twenty-nine patients achieved hemostasis within 10 minutes of product application (96.7% success rate; 1-sided 95% confidence interval, 85.1%-100%). The median total time to hemostasis including manual compression was 61 seconds. No complications, such as synechiae, adhesion, or infection, were reported.nnnCONCLUSIONSnSurgiflo hemostatic matrix with Thrombin-JMI was clinically effective in controlling bleeding in 96.7% of patients. Further randomized controlled trials are indicated.

Systemic Absorption of Gentamicin Nasal Irrigations

Objective To determine if gentamicin nasal irrigation is systemically absorbed, and to identify any ototoxic side effects related to its use. Design Retrospective review of 12 patients treated with gentamicin nasal irrigations (30 cc of 80 mg/L solution used bilaterally twice daily). Methods Serum gentamicin levels were assayed after the course treatment. Pure tone audiometry (250–8000 Hz) and distortion product otoacoustic emissions (DP-OAEs) at 7280, 5133, 3640 and 2560 Hz were obtained before and after therapy. Results Twelve patients (age 4 to 74, mean 43) with chronic rhinosinusitis were treated for 3–15 weeks (mean 7 weeks). All patients had undergone previous endoscopic sinus surgery. Ten patients had pretreatment cultures that grew organisms sensitive to gentamicin (Pseudomonas, Proteus, or methacillin resistant Staphylococcus aureus), and three patients had cystic fibrosis. Ten of 12 patients (83%) had detectable posttreatment levels of gentamicin, with a mean serum level of 0.42 mcg/mL (range 0.3 to 0.7 mcg/mL). Four of 12 patients (33%) had serum gentamicin levels within the normal range for gentamicin trough (0.5 to 2 mcg/mL). Comparison of pre- and posttreatment audiologic data revealed no significant change in PTA or DP-OAE, except for the right ear at 8000 Hz on PTA (p = 0.035) where a mean of 7 dB loss was observed. No patient reported hearing loss or vertigo during treatment. Conclusion Gentamicin nasal irrigation may be systemically absorbed. Although the otologic consequences of this finding are questionable, patients receiving gentamicin nasal irrigations should be counseled regarding this hypothetical possibility.

Endoscopic management of failed frontal sinus obliteration.

Background Frontal sinus obliteration (FSO) traditionally has represented the final stage in the algorithm for difficult to manage frontal sinus disease. In addition, FSO has been used in selected cases of frontal sinus trauma. However, this procedure has been associated with failure in 5–10% of cases. Advances in surgical instrumentation and image-guided surgical navigation have permitted endoscopic management of these failures. Methods Eleven patients presenting with failure of a previously performed FSO were managed endoscopically with the assistance of image-guided surgical navigation. Results Initial frontal sinus pathology included chronic inflammatory disease in six patients and frontal sinus trauma in two patients. Two patients underwent obliteration after neurosurgical frontal craniotomy and one patient underwent obliteration after curettage of a frontal sinus ossifying fibroma. Frontal sinuses were obliterated with fat in eight cases, bone chips in two cases, and bone cement in one case. The mean time interval to FSO failure was 11.1 years (range, 4 months–35 years). The etiology of failure included mucocele in eight patients, chronic frontal sinusitis in two patients, and Potts puffy tumor in one patient. All 11 patients were managed endoscopically, of which 3 patients underwent a trans-septal frontal sinusotomy. Two patients required revision endoscopic surgery, but all were patent at last follow-up (mean, 14.8 months). Conclusion Endoscopic management of failed FSO may be performed safely. These approaches are viable alternatives to open revision procedures in the management of failed FSO. (American Journal of Rhinology 18, 279–284, 2004)

Sclerosing rhabdomyosarcoma: A rare variant with predilection for the head and neck

Objectives/Hypothesis: Sclerosing rhabdomyosarcoma is a newly described variant of rhabdomyosarcoma with a predilection for the head and neck. Little has been written on the topic, because of the scarcity of the disease and its recent recognition as a distinct entity. The present report describes the fifth confirmed case of sclerosing rhabdomyosarcoma and is the first report in the otolaryngology literature.

Frontal Sinus Fractures in Children

Objective: To review the epidemiologic characteristics, clinical course, and management of pediatric patients with frontal sinus fractures.

The resident 80-hour work week: How has it affected surgical specialties?

Objectives: To identify strategies employed by surgical departments to address recently implemented resident duty hour regulations, and to assess resident and faculty acceptance of these changes.

Epidermoids of the paranasal sinuses and beyond: endoscopic management.

Background Epidermoid tumors of the craniofacial skeleton are uncommon, with the exception of acquired cholesteatoma of the temporal bone. These lesions may be primary embryologic in origin or, less frequently, may be iatrogenic or posttraumatic. Methods We report three cases of unusually encountered epidermoids, all of which were managed by endoscopic marsupialization via paranasal sinus approaches. We also review the pathophysiology and clinical presentation of these rare entities. Results The first patient is a 60-year-old man with a congenital epidermoid of the petrous apex removed via an endoscopic transsphenoid approach assisted by image-guided surgical navigation with CT/MRA merge. The second case is a 48-year-old woman with a history of trauma found to have a mass in the pterygopalatine space. An endoscopic transmaxillary approach was used to ligate the internal maxillary artery and marsupialize the cyst into the maxillary sinus. The third patient is a 22-year-old woman with a supraorbital ethmoid epidermoid tumor discovered intraoperatively during surgery for a presumed mucocele. This patient also had a known history of trauma. The cyst was marsupialized into the adjacent frontal sinus. Image-guided surgical navigation using CT was performed in the latter two cases. All patients are free of recurrence with follow-up ranging from 14 to 26 months. Conclusion With advancements in endoscopic techniques, including the use of image guidance, many of these relatively uncommon lesions can be managed by minimally invasive approaches via the paranasal sinuses.