Thomas A. Tami

Endoscopic anatomy of the sphenopalatine and posterior nasal arteries: implications for the endoscopic management of epistaxis.

Background Refractory posterior epistaxis is a challenge for otolaryngologists. Most algorithms for managing this condition ultimately call for interrupting the arterial blood supply to the nasal mucosa. Traditionally, this was accomplished either by transantral arterial ligation or by arteriographic-guided embolization. More recently, the endonasal endoscopic approach has also been described. Because the primary blood supply to the posterior nasal cavity is derived from the terminal branches of the sphenopalatine and the posterior nasal arteries, we conducted this anatomic study to examine and describe the anatomic relationship of these two arteries as they exit the pterygopalatine fossa and enter the nasal cavity. Methods We performed endoscopic dissections of this anatomic region in nine fresh and one formalin-preserved cadaver specimens. A total of 19 sides were examined. Results In 3 of 19 specimens (16%), the sphenopalatine artery branched from the sphenopalatine artery within the sphenopalatine canal, allowing the two arteries to exit together. In 8 of the 19 specimens (42%), the sphenopalatine artery exited much more posteriorly, yet from within a shared posteriorly elongated sphenopalatine foramen. In the remaining eight specimens (42%), the sphenopalatine artery exited through a distinct foramen directly posterior to the larger sphenopalatine foramen. Conclusion Understanding this anatomic relationship is important in performing endoscopic arterial ligation. If the sphenopalatine artery is not specifically identified and ligated, an important component of the posterior nasal circulation will not be addressed adequately by this surgical approach.

Ear, nose, and throat manifestations of sarcoidosis

Sarcoidosis rarely affects the head and neck and represents a diagnostic challenge to the otolaryngologist. The signs and symptoms of sarcoidosis in this area are not specific and can mimic much more common disorders. Biopsy is usually necessary to make the diagnosis. Appropriate evaluations and referrals should be made once there is suspicion of sarcoidosis. Steroids remain the mainstay of the therapeutic options; however, newer agents are being used more frequently. Long-term treatment and follow-up are necessary, because the disease tends to progress and to respond unpredictably to treatment.

Invasive fungal sinusitis in the acquired immunodeficiency syndrome

Invasive fungal sinusitis can present as either an indolent or fulminant process that primarily affects immunocompromised individuals. In this article, the clinical characteristics of four cases of invasive fungal sinusitis in patients with AIDS are analyzed and 22 additional previously reported cases in the literature are reviewed. In addition to HIV infection, other variables common to these cases include facial pain or headache out of proportion to clinical or radiographic findings, CD4 lymphocyte count less than 50 cells/mm(3), absolute neutrophil count less than 1,000 cells/mm(3), subtle radiographic evidence suggesting invasion and an indolent clinical course of the invasive infection. The most common pathogen detected was Aspergillus fumigatus. Maintaining a high index of suspicion, critically assessing these clinical findings, and prudently reviewing CT scans may facilitate early diagnosis and prompt intervention in these patients.

Surgical management of lesions of the sphenoid lateral recess.

Background Pneumatization of the sphenoid sinus occasionally includes an extensive lateral recess creating an area beneath the temporal lobe that is relatively inaccessible to surgical intervention. Pathology in this anatomic location presents special surgical and therapeutic challenges. Recently, several authors have described the endoscopic transpterygopalatine fossa approach to this anatomic region. This approach is associated with minimal morbidity while providing direct endoscopic surgical access for managing a variety of disease processes in this region. Methods This study presents eight cases requiring this approach or a modification of this approach. Six patients presented with temporal lobe meningoencephaloceles with cerebrospinal fluid rhinorrhea. Each case was managed successfully through this surgical approach. Results One patient experienced transient postoperative palatal anesthesia due to injury to the greater palatine nerve and another complained of ipsilateral dry eye postoperatively. Two other patients had neoplasms (inverting papilloma and chondrosarcoma), which were successfully addressed through this technique. There were no postoperative complications in these patients. Conclusion We have previously described the relationships of neural and vascular structures in this anatomic region. This article will review these relationships as they pertain to this surgical approach and will discuss the indications, techniques, and surgical outcomes in this series of patients. This approach is a valuable addition to the endoscopic armamentarium of the experienced endoscopic surgeon.

Methicillin-resistant Staphylococcus aureus (MRSA) in the practice of otolaryngology--an emerging community acquired organism?

Soon after antibiotics were introduced to treat bacterial infections, resistance to these agents began to emerge. Staphylococcus aureus, a common organism in human infection, quickly became resistant to penicillin; however, semisynthetic penicillins seemed to have tremendous staying power. The recent emergence of methicillin-resistant S. aureus (MRSA) created a difficult problem in treating many hospital-acquired infections soon after it was discovered. However, now it appears to be spreading into the community at large. Although newer antibiotics have been developed to help manage this threat, multiple-drug resistance remains a fear among healthcare professionals. Eradication of MRSA appears to be an unachievable goal at this time, so attention has focused on decreasing the spread of this organism, often through simple hand-washing protocols. The continued spread of MRSA will have tremendous impact on the practice of medicine and otolaryngology during the next decade and beyond.

Advances in treating the common cold: an update for otolaryngologists

Even though the common cold is one of the most common infections experienced by modern society, its origins, pathophysiology, and treatment remain poorly understood by the lay person and by many medical professionals. This article presents and discusses the pathophysiology of these viral infections and numerous studies that support or refute the effectiveness of several common treatment modalities, including antibiotics, antihistamines and decongestants, anticholinergics, mast cell stabilizers, herbal medicines, zinc, and steam therapy. This article also reviews several newer antiviral agents that have recently been evaluated in clinical trials and that may ultimately provide a starting point for development of effective cold therapies.

The use of thalidomide in contemporary medical practice: revival of a medical pariah

despair for those people who remember the disfiguring birth defects produced by its use during pregnancy in the mid1950s. This drug, more than any other, created an awareness and emphasis on the potential adverse effects of taking medications during pregnancy and has been relegated to a position in medical practice as a great pariah. Nevertheless, things never stay the same. The passage of time has allowed medical professionals to take a second look at the potentially beneficial effects of this agent. As a result, we are witnessing a rebirth of thalidomide in clinical medicine. Anti-inflammatory effects, potential chemotherapeutic indications, and sedative effects (the primary indication for its initial use) are now being given serious clinical consideration. The Food and Drug Administration has recently approved its use for a single indication, and other indications are in the wings. This article will review the current role of thalidomide in clinical medicine. Curr