Stilianos E. Kountakis

Endoscopic optic nerve decompression for traumatic blindness.

OBJECTIVES: The goal of this study was to compare the outcome of patients with traumatic optic neuropathy (TON) treated with high-dose steroids with the outcome of patients with TON treated with endoscopic optic nerve decompression (EOND) after failing high-dose steroid treatment. METHODS: During this retrospective review of patients with TON seen from 1994 to 1998, all patients were first treated with megadose methylprednisolone for 48 hours. Patients with no improvement or with worsening visual acuity were offered EOND. RESULTS: Eleven of 34 (32%) patients treated with high-dose steroids showed improvement, and 23 (68%) did not. Seventeen of the 23 patients without improvement after high-dose steroid treatment underwent EOND. Fourteen of 17 (82%) surgically treated patients had improved visual acuity, and 3 (18%) did not, with an overall improvement in 25 of 34 (74%) patients (χ2 = 11.338, P = 0.0007). CONCLUSION: EOND is an appropriate treatment technique for patients with TON in whom high-dose steroid treatment has failed. (Otolaryngol Head Neck Surg 2000;123:34-7.)

Significance of computed tomography pathology in chronic rhinosinusitis

Objectives/Hypothesis Multiple reports show that the extent of disease on computer tomography (CT) of the sinuses does not correlate with patients subjective sinus symptom scores. In the current study, sinus symptom scores of patients with normal findings on sinus CT scans are compared with sinus symptom scores of patients with chronic rhinosinusitis and with disease on CT of the sinuses. The objective is to determine the significance of CT disease in patients with chronic rhinosinusitis.

Cysteinyl leukotrienes in chronic hyperplastic rhinosinusitis

OBJECTIVES: Our study was designed to demonstrate that, similar to asthma, eosinophilic chronic rhinosinusitis is a disease characterized by activation and the expression of cysteinyl leukotrienes (LTs). METHODS: Nasal polyp tissue was evaluated from 28 consecutive individuals undergoing elective polypectomy in whom neutrophils were not present on pathologic examination. Tissue was analyzed for pathosis with particular attention to the presence of eosinophils. Patients with moderate to high levels of mucosal eosinophils were classified as having eosinophilic rhinosinusitis (ECRS). Those with few or absent mucosal eosinophils were classified as having noneosinophilic rhinosinusitis (NECRS). Cysteinyl LTs were quantified by a sensitive competitive enzyme immunoassay, and the levels of cysteinyl LTs were compared in the groups. RESULTS: There were 20 patients with ECRS and 8 patients with NECRS. Cysteinyl LTs were identified in polyp tissue from 24 of 28 subjects and were >5 pg/gm tissue in 15 of 28. The average level of LTC4 in patients with few mucosal eosinophils was 38.3 pg/g. The average amount in those with moderate to large amounts of mucosal eosinophils was 36.7 pg/g. There was no significant difference between the 2 groups. CONCLUSION: ECRS and NECRS can be considered diseases of excessive expression of cysteinyl LTs. LT expression occurs in patients who demonstrate few or no mucosal eosinophils, which indicates that cell lines other than eosinophils may be responsible for LT production in chronic rhinosinusitis.

Long-term results of the Lothrop operation.

With continued surgical instrument advancement, endoscopic sinus surgery techniques continue to evolve with an overall improvement of our ability to offer surgical treatment for a variety of surgical disorders of the sinuses and anterior skull base. Frontal sinusitis and the extent of surgery performed in the frontal recess once medical management fails are constantly debated in the literature. It seems that even though instrumentation has greatly improved, surgical management of frontal sinusitis remains a frustrating endeavor for otolaryngologists. Open approaches to the frontal sinus, including the osteoplastic flap with frontal sinus obliteration using adipose tissue, have been the gold standard, but require external incisions and complete removal of sinus mucosa with destruction of the frontal sinus. The endoscopic modified Lothrop technique involves removal of the frontal sinus floor bilaterally with frontal septectomy and resection of the nasal septum to create a large nasofrontal communication. Recent postoperative results of this technique rival the results after frontal sinus obliteration in selected patients while avoiding the morbidity associated with the open destructive approach.

Middle meatal vs antral lavage cultures in intensive care unit patients

OBJECTIVE: The study goal was to compare endoscopically guided middle meatal cultures with cultures of antral lavage aspirate in intensive care unit (ICU) patients with sinusitis. METHODS: Prospective study of febrile ICU patients seen for sinusitis at a tertiary medical center. RESULTS: Of 31 antral lavages performed in 18 patients, 19 lavages yielded purulent or mucopurulent aspirate. Endoscopically guided middle meatal cultures yielded the same pathogen, as did cultures of the lavage aspirate in 4 (21%) of these 19 cases. The antral lavage was negative (absence of purulent/mucopurulent aspirate) in 12 cases, and of those, 5 (42%) of the 12 middle meatal cultures showed no growth (sensitivity = 21%, specificity = 58%, χ2-1.52, P = 0.218). CONCLUSION: Endoscopically guided middle meatal cultures did not correlate well with cultures from the antral lavage aspirate in febrile ICU patients evaluated for sinusitis.

Evaluation of sinusitis in the intensive care unit patient.

OBJECTIVEnThe purposes of this study were to evaluate the effectiveness of radiologic studies in diagnosing sinusitis in the intensive care unit (ICU) patient and to compare it with the effectiveness of endoscopic examination of the middle meatus.nnnMETHODSnWe conducted a prospective collection of data in 141 ICU patients consulted for sinusitis over a 5-year period beginning in the 1994.nnnRESULTSnAntral lavage was performed at least unilaterally in 112 patients, with a total of 195 lavages performed. Plain films and computer tomography scans predicted purulence in 41% (chi(2) = 2.9, P = 0.09) and 47% (chi(2) = 2.2, P = 0.14) of the cases, respectively, whereas the presence of purulence in the middle meatus as seen on endoscopy predicted purulence in the maxillary sinus in 78% of the lavages (chi(2) = 28.9, P = 8 x 10(-8)). When there was no evidence of purulence in the middle meatus on endoscopy, 73% of the lavages were negative.nnnCONCLUSIONnThe most important predictor of a positive antral lavage in the ICU patient with suspected sinusitis is evidence of purulence on endoscopic examination of the middle meatus.

Skull base erosion by sphenoid fungus balls: diagnosis and endoscopic treatment.

Background Fungus balls typically are innocuous lesions found in immunocompetent hosts. They are located most commonly in the maxillary sinus but may be life-threatening when found in the sphenoid sinus. Methods We review our series of four sphenoid fungus balls with skull base erosion. Results Our average patient age was 68.7 years old (56–86 years) with three women and one man. One patient was insulin-dependent diabetic, the other three patients were otherwise healthy. The most common presenting symptoms were headache and dizziness with relatively few sinus-specific complaints. Endoscopy revealed polyps in two of the four patients. Computerized tomography scans revealed thickened osteitic bone in three cases and two of the four computed tomography scans showed microcalcification. All patients had bony erosion over the internal carotid arteries. Additionally, one patient internal carotid artery thrombosis, one patient had erosion of the planum sphenoidale, and a third patient had erosion to the brainstem inferior to the sella turcica. Three patients had magnetic resonance imaging that revealed heterogeneous lesions. Two magnetic resonance images showed hypointense T1 and T2 imaging. The third was isointense on T1 and hypointense on T2. All patients were treated with endoscopic marsupialization and removal of all gross fungal debris without complications. All pathological specimens were diagnostic for fungus balls. One of four cultures was positive for fungus. All patients are asymptomatic at time of last follow-up. Conclusions Sphenoid fungus balls present with vague, non-rhinological symptoms, but may have significant local expansion and destruction. These potentially lethal lesions usually can be suspected on preoperative imaging and are best treated with endoscopic removal.

Parathyroid adenomas: Is bilateral neck exploration necessary?

PURPOSEnThe traditional surgical treatment for primary hyperparathyroidism is bilateral neck exploration with identification of all parathyroid glands. Multiple investigators who recommend initial unilateral neck exploration based on more advanced localization studies have recently challenged this approach. We reviewed our experience with primary hyperparathyroidism to determine if localization study-aided unilateral neck exploration is sufficient for a cure.nnnMATERIALS AND METHODSnRetrospective chart review of patients with primary hyperparathyroidism.nnnRESULTSnSixty-eight patients underwent surgery for primary hyperparathyroidism. Forty-four patients were treated with localization study-aided unilateral neck exploration, and 24 patients were treated with bilateral neck exploration without preoperative localization studies. The most successful preoperative localization study was the technetium 99m sestamibi (T99mS) scan which correctly identified the location of adenomas in all cases in which it was used (n = 15). All patients were treated with unilateral neck exploration and were cured. This success was matched only by surgical exploration (n = 24).nnnCONCLUSIONnUnilateral neck exploration based on the results of a T99mS scan can be used as an initial approach for primary hyperparathyroidism if the scan identifies a solitary lesion. The second gland on the same side of the lesion should be biopsied, and if it is normal, the opposite side of the neck may be left undisturbed. If the second gland is not normal, or if the T99mS scan shows multiple lesions, bilateral neck exploration should be performed.

Presence of Cysteinyl leukotrienes in asthmatic patients with chronic sinusitis

Introduction The association between asthma and sinusitis has long been recognized. Numerous studies point to a complex, yet undeniable relationship between asthma and chronic sinusitis and rhinitis. There have also been extensive attempts to characterize the inflammatory mechanisms of both disorders. Increasingly, the cysteinyl leukotrienes, a potent group of inflammatory mediators, have gained attention as important contributors to the manifestation of both disorders. Leukotriene production has been shown to be upregulated in the bronchial tissue of asthmatics. Our study sought to determine if leukotriene production was increased in the sinus mucosa of asthmatics with chronic sinusitis.

Migration of intradural epidermoid matrix: embryologic implications.

The migratory behavior of acquired cholesteatoma matrices (those arising from the tympanic membrane) has been described previously. This tissue is derived embryologically from the first branchial groove and represents the only migratory epithelium arising from the branchial groove system. If the matrix from a cerebellopontine angle (CPA) epidermoid tumor exhibits migratory behavior similar to that of acquired cholesteatomas, a first branchial groove site of origin for CPA epidermoids would be supported. Intradural CPA epidermoid cells were grown in a—minimum essential medium. The cultures were examined daily, and cell mass migration rates were measured. It was observed that intradural epidermoid tumor matrix harvested from the CPA exhibited migration in vitro. Its migratory properties were indistinguishable from those of acquired cholesteatomas, which are embryologically derived from the first branchial groove. These data support the theory that purely intradural epidermoids are derived from cells of the first branchial groove.