Salil Nair

Endoscopic removal of sinonasal inverted papilloma including endoscopic medial maxillectomy

Objectives/Hypothesis Surgical excision is regarded as the treatment of choice for sinonasal inverted papilloma. Resection can be performed endoscopically or through an external approach. Debate exists about which approach to use. The study presents different endoscopic techniques for various tumor locations and reviews the results.

Correlation between preoperative symptom scores, quality-of-life questionnaires, and staging with computed tomography in patients with chronic rhinosinusitis.

Background This study evaluates the correlation between preoperative symptoms, quality-of-life questionnaires (chronic sinusitis survey and 20-Item Sinonasal Outcome Test [SNOT-20]), and staging on computer tomography (CT). It consisted of a prospective cohort study of all consecutive patients undergoing surgery for medically nonresponsive chronic sinusitis, which took place at a tertiary care center. Methods Two hundred twenty-one patients completed the Chronic Sinusitis Survey (CSS) questionnaire and the SNOT-20. A visual analog scale (VAS) symptom score was completed also. The average age of the patients was 44.5 years and the male/female ratio was 1.3:1. The symptom scores of all three questionnaires were compared with the Lund-MacKay CT scan score of the sinuses. Results The median Lund-MacKay CT score was 12 (mean ± SD, 12.7 ± 5.7). There was no significant correlation between the SNOT-20 questionnaire and the Lund-MacKay CT score (p = 0.026; p = 0.764) and between the CSS and the Lund-MacKay CT score (p = —0.158; p = 0.058). Furthermore, there was no significant correlation between a single VAS symptom score relating to overall sinonasal symptom severity and the Lund-MacKay CT scan score (p = 0.135; p = 0.121). However, a weak but statistically significant correlation was found between the VAS score based on the sum of five sinonasal symptoms and the Lund-MacKay CT scan score (p = 0.197; p = 0.020). Conclusion The score, based on the sum of five sinonasal VAS symptoms, correlates to the disease severity as measured by the Lund-MacKay CT scan score. The SNOT-20 questionnaire and the CSS symptom score do not correlate to the Lund-MacKay CT scan score, although a correlation was found between the CSS score and the Lund-MacKay CT score in various subgroups of our patient population.

The Effect of β-Blocker Premedication on the Surgical Field During Endoscopic Sinus Surgery

Objectives/Hypothesis: A number of previous studies have tried to assess the effects of hypotension on the surgical field during endoscopic sinus surgery. These studies have been limited by inadequate sample sizes, lack of a control group, and limited data collection. The aim of the present study was to determine whether the routine use of β‐blockers as a pre‐medication could improve the operative field in endoscopic sinus surgery.

Role of local immunoglobulin E production in the pathophysiology of noninvasive fungal sinusitis

Objectives/Hypothesis: Immunoglobulin (Ig)E‐mediated hypersensitivity to fungi has been postulated to explain allergic fungal sinusitis (AFS). Not all patients suspected to have AFS demonstrate systemic evidence of allergy. Locally produced IgE might explain those patients with no systemic evidence of allergy but clinical features of AFS. The aim was to determine whether fungal‐specific IgE could be demonstrated in sinus mucin in patients with eosinophilic mucin rhino‐sinusitis.

Endoscopic Anterior Ethmoidal Artery Ligation: A Cadaver Study

Objective: The objective of this study was to investigate the radiologic and endoscopic anatomy of the anterior ethmoidal canal (AEC) and feasibility of endoscopic ligation of the anterior ethmoidal artery (AEA).

Modified endoscopic lothrop as a salvage for the failed osteoplastic flap with obliteration

Objective: To evaluate the effectiveness of the modified endoscopic Lothrop (MEL) procedure for the management of failed osteoplastic flap (OPF) with obliteration of the frontal sinuses. Setting: Adelaide University Academic Hospital Complex. Study Type: Prospective case study of 16 patients presenting with symptoms after OPF with obliteration of the frontal sinuses. Materials and Methods: Sixteen patients presented with symptoms of frontal sinus pain after having previously undergone OPF and fat obliteration of the frontal sinuses. All patients underwent computed tomography scanning; 13 underwent magnetic resonance imaging scanning, and 6 underwent a bone scan with technetium to exclude frontal osteitis. All patients underwent exploration of the frontal sinuses by way of the MEL procedure. Results: Fifteen patients were found to have a frontal sinus mucocele, whereas one patient had no mucocele with only new bone and fibrous tissue found at the MEL procedure. Twelve of the 16 patients with mucoceles had resolution of their frontal headaches, with 15 having a patent and healthy communication between the mucocele and the nasal cavity. The one patient without a mucocele continues to have frontal pain. One patient underwent a successful MEL procedure but had persistent symptoms until a supraorbital ethmoid mucocele was removed at a revision procedure. Two other patients continued to have frontal headaches and pain despite a healthy ostium into the frontal sinus mucocele. Conclusions: MEL is a viable alternative to revision OPF for symptomatic patients who are shown to have a mucocele of the frontal sinuses.

Nasopharyngeal pH Monitoring in Chronic Sinusitis Patients Using a Novel Four Channel Probe

Objective: To determine the prevalence of acid reflux into the nasopharynx in patients with chronic sinusitis.

Prevalence of noninvasive fungal sinusitis in South Australia.

Background The aim of this study was to document the prevalence of noninvasive fungal sinusitis in patients with chronic sinusitis and thick viscous secretions in South Australia. Methods We studied of 349 patients with chronic rhinosinusitis undergoing endoscopic sinus surgery in a specialized rhinology practice. Patients with nasal polyposis and thick fungal-like sinus mucin had operative samples sent for microscopy and fungal culture. Evidence of atopy was taken as positive radioallergosorbent or skin-prick tests to fungi. Results One hundred and thirty-four (38%) patients were noted to have thick, viscid sinus mucin, raising suspicion of fungal disease. Ninety-three patients had positive fungal cultures or microscopy (26.6%). It was possible to classify 95.5% of the patients into subgroups of noninvasive fungal sinusitis or nonfungal sinusitis: 8.6% of patients with allergic fungal sinusitis, 1.7% of patients with allergic fungal sinusitis–like sinusitis, 15.2% of patients with chronic fungal sinusitis, one patient with a fungal ball, and the remaining 69% of patients with nonfungal chronic sinusitis. Conclusion This is the first prospective study to evaluate the prevalence of these increasingly widely recognized conditions. It highlights the need for otolaryngologists to be alert to these not uncommon diagnoses in order for early, appropriate medical and surgical management to be instituted.

Effect of using multiple culture media for the diagnosis of noninvasive fungal sinusitis

Background This study was designed to assess the relative efficiency of three different culture media for isolating fungi in patients suspected of having noninvasive fungal sinusitis. Methods A prospective study was performed of 209 operative samples of sinus “fungal-like” mucin from 134 patients on 171 occasions and processed for microscopy and fungal culture in Sabourauds dextrose agar, potato dextrose agar, and broth media. Results Ninety-three (69%) of 134 patients had evidence of fungal infection. Two-thirds of patients had negative microscopy samples yet 56% of these went on to positive cultures. Forty-five percent cultured Aspergillus genus. Discrepancy between the fungi cultured in different media and on different occasions was common. With a single culture medium up to 19% of patients and 15% of samples would have been falsely labeled fungal negative. Conclusion Increasing the number and type of fungal culture media used increases the number and range of fungal isolates from mucin in patients with the features of fungal sinusitis. Negative specimen microscopy is unreliable. All specimens should be cultured in multiple media and on multiple occasions when fungal sinusitis is suspected.

Transillumination-Assisted Maxillary Trephination: Cadaver Validation of a New Technique

INTRODUCTION Endoscopic sinus surgery is performed on patients with chronic rhinosinusitis who have previously failed medical therapy. The maxillary sinus is one of the most commonly affected, and endoscopic access is typically through uncinectomy and middle meatal antrostomy (MMA). Difficulties in reaching the anterior and inferior portions of the sinus have been noted due to limitations of rigid endoscopic equipment. The canine fossa puncture has been suggested as a secondary route of surgical access, and was initially described as a trochared puncture through the canine fossa, superior to the root of the canine tooth, inferior to the infraorbital foramen, medial to the zygomatic buttress, and lateral to the pyriform aperture. Recently, an updated anatomical study has described new landmarks, namely a trephination at the intersection of the midpupillary line and the horizontal line through the floor of the nasal vestibule. Cadaveric studies have shown this to be the optimum position for avoiding damage to the plexuses of the anterior superior alveolar nerve (ASAN) and middle superior alveolar nerve (MSAN), and the potential sequelae of cheek swelling, dental numbness, facial numbness, tingling, and pain. We present a modification of this technique that uses transillumination of the anterior wall of the maxillary sinus to identify the major trunks of the ASAN and MSAN, followed by an accurately drilled trephination to gain surgical access to the sinus, and a cadaveric study to assess nerve injuries in heads that have undergone canine fossa trephination (CFT) using updated anatomical landmarks. Subsequent to this cadaveric study, we tested this method of locating the optimum trephination position in patients who required CFT as part of the operative management of sinus disease.