Efficacy of glucocorticoid stent implantation in ethmoid sinus after endoscopic sinus surgery for chronic rhinosinusitis with nasal polyps / 临床耳鼻咽喉头颈外科杂志

Objective:To evaluate the efficacy of glucocorticoid sinus stents implanted 2 weeks after functional endoscopic sinus surgery（FESS） for the treatment of chronic rhinosinusitis with nasal polyps（CRSwNP）. Methods:CRSwNP patients with similar bilateral lesions were randomly divided into two groups, with a stent group of 25 patients and a control group of 24 patients. Patients in the stent group had glucocorticoid sinus stents implanted into the bilateral ethmoid sinuses 2 weeks after FESS, while the control group underwent postoperative debridement only. Follow-up assessments occurred at postoperative weeks 2, 4, 8, and 12. Patients were asked to assess their sensation of nasal symptoms using a 10-point visual analog scale. Efficacy was assessed by endoscopic evaluations. Sinus obstruction, crusting/coagulation, polyp formation, middle turbinate position, adhesions, mucosa epithelialization, and postoperative intervention were assessed as efficacy outcomes. GraphPad Prism 9 was applied for statistical analysis. Results:At 4 and 8 weeks postoperatively, the stent group showed significant improvement in VAS scores of nasal congestion and runny nose compared with the control group（P<0.05）. No significant difference was observed in the VAS scores of head and facial stuffiness, loss of smell, or nasal dryness/crusting between the two groups（P>0.05）. Compared with the control group, the stent group had a lower rate of polypoid formation at 4, 8, and 12 weeks postoperatively. At postoperative week 12, the rate of mucosal epithelialization in the ethmoid cavity was significantly higher in the stent group. During the follow-up, the frequency of postoperative intervention was significantly lower in the stent group than in the control group（P<0.05）. Besides, a lower incidence of middle turbinate lateralization was found in the stent group at 8 and 12 weeks postoperatively. At 8 weeks postoperatively, the stent group had a percentage of adhesion lower than that of the control group（all P<0.05）. Conclusion:Implantation of glucocorticoid sinus stents after FESS can maintain sinus cavity patency, improve the inflammatory status of the operative cavity, reduce postoperative interventions, and promote benign regression of the operative cavity.

In Vivo Computed Tomography Direct Volume Rendering of the Anterior Ethmoidal Artery: A Descriptive Anatomical Study

Abstract Introduction The clinical relevance of the anatomy and variations of the anterior ethmoidal artery (AEA) is outstanding, considering its role as a landmark in endoscopic surgery, its importance in the therapy of epistaxis, and the high risks related to iatrogenic injuries. Objective To provide an anatomical description of the course and relationships of the AEA, based on direct computed-tomography (CT)-based 3D volume rendering. Methods Direct volume rendering was performed on 18 subjects who underwent (CT) with contrast medium for suspected cerebral aneurism. Results The topographical location of 36 AEAs was assessed as shown: 10 dehiscent (27.8%), 20 intracanal (55.5%), 6 incomplete canals (16.7%). Distances from important topographic landmarks are reported. Conclusion This work demonstrates that direct 3D volume rendering is a valid imaging technique for a detailed description of the anterior ethmoidal artery thus representing a useful tool for head pre-operatory assessments.

Clinical Manifestations and Computed Tomography Findings of Trapdoor Type Medial Orbital Wall Blowout Fracture

PURPOSE: To report the clinical manifestations and computed tomography (CT) findings of patients with a trapdoor type medial orbital wall blowout fracture.METHODS: From March 2009 to October 2016, the clinical records and computed tomography findings of patients who underwent surgical treatment for a trapdoor type medial orbital wall blowout fracture were retrospectively analyzed.RESULTS: A total of eight patients (six males and two females) were enrolled with a combined mean age of 14.4 years. Clinical manifestations were eyeball movement limitation (abduction and adduction) and ocular motility pain (eight patients, 100%), diplopia (seven patients, 87.5%), and nausea and vomiting (four patients, 50%). On CT, the distance from the orbital apex to the fracture site was an average of 22.0 mm and occurred in the middle position of the entire wall. Two patients had missed rectus completely dislocated into the ethmoid sinus through the fracture gap and six patients had definite involvement in the fracture gap and edema of the medial rectus muscle. The medial rectus muscle cross-sectional area was 47.7 mm² which was edematous compared to the contralateral eye (40.1 mm²). Orbital wall reconstruction was performed an average of 4.1 days after the injury. In all patients with oculocardiac reflex-like nausea and vomiting immediately improved after surgery. Six out of eight patients who had eyeball movement limitations (abduction and adduction) preoperatively showed adduction limitation after surgery. The eyeball movement limitation and diplopia disappeared 11.7 days and 46.7 days after surgery, respectively.CONCLUSIONS: Patients with trapdoor type medial wall blowout fracture showed characteristic computed tomographic findings and clinical manifestations such as eyeball movement limitation, ocular motility pain, diplopia, and oculocardiac reflex. An understanding of clinical findings and quick surgical treatment are therefore required. The type of eyeball movement limitation was abduction and adduction limitation preoperatively and adduction limitation postoperatively.

Complicación orbitaria recurrente por rinosinusitis. Reporte de un caso / Recurrent orbital complication by rhinosinusitis. A case report

El compromiso orbitario es la complicación más frecuente de la rinosinusitis aguda en pediatría, y el etmoides es el seno más afectado. La recurrencia es infrecuente. Existen solo tres casos publicados en la literatura. Una anomalía anatómica del proceso unciforme o un mucocele podrían ser factores predisponentes, que pueden obstruir el drenaje normal de los senos junto con la presencia de etmoiditis.La tomografía computada y la resonancia magnética orientan el diagnóstico. El tratamiento quirúrgico está indicado ante la falta de respuesta al tratamiento instaurado luego de 48 horas o disminución de la agudeza visual o recurrencias sin patología tumoral de base.Se presenta a un paciente de 4 años de edad que consultó por un cuadro compatible con etmoiditis complicada recurrente. Presentó celulitis preseptal en seis oportunidades y un episodio de absceso subperióstico, desde los 3 meses de edad. Evolucionó favorablemente luego de la operación quirúrgica.

Orbital infection is the most frequent complication of ethmoiditis. Recurrent periorbital cellulitis is a very rare complication of rhinosinusitis with only three reports in the literature describing this pathological process.This complication can be favored by an anatomical abnormality of the uncinate process or mucocele obstructing the normal drainage pathway, in addition to ethmoidal sinusitis.Computed tomography and magnetic resonance guide the diagnosis. The treatment is based on antibiotics, corticosteroids and local decongestants. Surgical treatment is indicated in the absence of response to treatment established after 48 hours or decrease in visual acuity or recurrent orbital complications without underlying tumor pathology. In this report, we present a case of orbital complication of rhinosinusitis in a 4 year-old-child with six episodes of unilateral periorbital cellulitis and one episode of subperiosteal orbital abscess since the age of 3 months. There was a complete resolution with no recurrence after the surgical intervention

Orbital wall restoring surgery with primary orbital wall fragments in blowout fracture

Most orbital surgeons believe that it's difficult to restore the primary orbital wall to its previous position and that the orbital wall is so thin that cannot be firmly its primary position. Therefore, orbital wall fractures generally have been reconstructed by replacing the bony defect with a synthetic implant. Although synthetic implants have sufficient strength to maintain their shape and position in the orbital cavity, replacement surgery has some drawbacks due to the residual permanent implants. In previous studies, the author has reported an orbital wall restoring technique in which the primary orbital wall fragment was restored to its prior position through a combination of the transorbital and transantral approaches. Simple straight and curved elevators were introduced transnasally to restore the orbital wall and to maintain temporary extraorbital support in the maxillary and ethmoid sinus. A transconjunctival approach provided sufficient space for implant insertion, while the transnasal approach enabled restoration of the herniated soft tissue back into the orbit. Fracture defect was reduced by restoring the primary orbital wall fragment to its primary position, making it possible to use relatively small size implant, furthermore, extraorbital support from both sinuses decreased the incidence of implant displacement. The author could recreate a natural shape of the orbit with the patient's own orbital bone fragments with this dual approach and effectively restored the orbital volume and shape. This procedure has the advantages for retrieving the orbital contents and restoring the primary orbital wall to its prior position.

Correlations between anatomical variations of the nasal cavity and ethmoidal sinuses on cone-beam computed tomography scans

PURPOSE: Anatomical variations of the external nasal wall are highly important, since they play a role in obstruction or drainage of the ostiomeatal complex and ventilation and can consequently elevate the risk of pathological sinus conditions. This study aimed to assess anatomical variations of the nasal cavity and ethmoidal sinuses and their correlations on cone-beam computed tomography (CBCT) scans. MATERIALS AND METHODS: This cross-sectional study evaluated CBCT scans of 250 patients, including 107 males and 143 females, to determine the prevalence of anatomical variations of the nasal cavity and ethmoidal sinuses. All images were taken using a New Tom 3G scanner. Data were analyzed using the chi-square test, Kruskal-Wallis test, and the Mann-Whitney test. RESULTS: The most common anatomical variations were found to be nasal septal deviation (90.4%), agger nasi air cell (53.6%), superior orbital cell (47.6%), pneumatized nasal septum (40%), and Onodi air cell (37.2%). Correlations were found between nasal septal deviation and the presence of a pneumatized nasal septum, nasal spur, and Haller cell. No significant associations were noted between the age or sex of patients and the presence of anatomical variations (P>0.05). CONCLUSION: Radiologists and surgeons must pay close attention to the anatomical variations of the sinonasal region in the preoperative assessment to prevent perioperative complications.

Proposal of a Pretreatment Nomogram for Predicting Local Recurrence after Intensity-Modulated Radiation Therapy in T4 Nasopharyngeal Carcinoma: A Retrospective Review of 415 Chinese Patients / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Local relapse-free survival (LRFS) differs widely among patients with T4 category nasopharyngeal carcinoma (NPC). We aimed to build a nomogram incorporating clinicopathological information to predict LRFS in T4 NPC after definitive intensity-modulated radiation therapy (IMRT). MATERIALS AND METHODS: Retrospective study of 415 Chinese patients with non-metastatic T4 NPC treated with definitive IMRT with or without chemotherapy at our cancer center between October 2009 and September 2013. The nomogram for LRFS at 3 and 5 years was generated based on multivariate Cox proportional hazards regression, and validated using bootstrap resampling, assessing discriminative performance using the concordance index (C-index) and determining calibration ability via calibration curves. RESULTS: Five-year LRFS was 88.8%. We identified and incorporated four independent prognostic factors for LRFS: ethmoid sinus invasion, primary gross tumor volume, age, and pretreatment body mass index. The C-index of the nomogram for local recurrence was 0.732 (95% confidence interval, 0.726 to 0.738), indicating excellent predictive accuracy. The calibration curve revealed excellent agreement between nomogram-predicted and observed LRFS probabilities. Risk subgroups based on total point score cutoff values enabled effective discrimination of LRFS. CONCLUSION: This pretreatment nomogram enables clinicians to accurately predict LRFS in T4 NPC after definitive IMRT, and could help to facilitate personalized patient counselling and treatment strategies.

Abducens Nerve Palsy and Optic Perineuritis Caused by Fungal Sphenoidal Sinusitis

PURPOSE: To report a case of abducens nerve palsy and optic perineuritis caused by fungal sphenoidal sinusitis. CASE SUMMARY: A 48-year-old male visited emergency department for retrobulbar pain, decreased vision, and horizontal diplopia for 3 days. He reported that previous medical history was non-specific, however, blood glucose level was 328 mg/dL (70–110). He had experienced severe headache for 7 days. The best corrected visual acuity was 20/20 at right eye and 20/25 at left eye. The pupil of left eye did not have relative afferent pupillary defect. Left mild proptosis was noted. The extraocular examination showed 30 prism diopters left esotropia at primary gaze and −4 abduction limitation of left eye. The left eye showed mild optic disc swelling and inferior field defect by field test. Brain magnetic resonance imaging showed enhancement of sphenoidal sinus, ethmoidal sinus, and around optic nerve at left eye. Three days after antibiotics treatment, the vision of left eye deteriorated to 20/40 and periorbital pain developed. The drainage and biopsy of sphenoidal sinus were performed. The histopathologic examination showed hyphae consistent with aspergillosis. The ocular symptoms were improved with anti-fungal treatment. Follow-up magnetic resonance imaging performed 1 month after treatment showed improvement of lesion at left orbit. Five months after surgery, the visual acuity of left eye was improved to 20/25. The patient showed orthotropia at primary gaze without limitation. CONCLUSIONS: The abducens nerve palsy and optic perineuritis can be caused by fungal sphenoidal sinusitis. The early diagnosis and appropriate treatment can lead to favorable outcome.

A Case of Orbital Chondroma

PURPOSE: To report a case of orbital chondroma. CASE SUMMARY: A 15-year-old male presented with an 8-month history of left hypertropia. The best-corrected visual acuity was 20/20 in both eyes. The exophthalmometry showed no exophthalmos, with 13 mm in both eyes. There was a hard palpable mass at the superonasal orbit of the left eye. Orbital computed tomography showed a heterogenous soft tissue shadow at the superonasal orbit of the left eye, and orbital magnetic resonance imaging revealed a 25 × 16 × 20 mm well-defined mass with low signal intensity in the T1-weighted image, high signal intensity in the T2-weighted image, and heterogenous enhancement in the contrast enhanced T1-weighted image. The mass was surgically removed with anterior orbitotomy. A 27 × 17 mm well-capsulated lobular mass was found, and histopathological examination revealed hyaline cartilage and chondrocyte. The mass was diagnosed as a chondroma. CONCLUSIONS: A chondroma is a benign tumor, which usually occurs in long bones and the small bones of the hands and feet. It is very rare in the facial and pelvic bones. The sites of chondroma occurring in the head and neck include the ethmoid sinus and maxilla, but it is extremely rare in the orbit.

A Case of Frontoethmoidal Mucopyocele Combined with Cerebrospinal Fluid Leak and Complicated Tension Pneumocephalus after Marsupialization

After the trauma of frontoethmoidal sinus, post-traumatic mucocele may occur. Surgical removal of the lesions rarely produces cerebrospinal fluid (CSF) leakage and even delayed tension pneumocephalus. We experienced a case of fronto-ethmoid mucocele complicated with peri-operative CSF leakage and post-operative tension pneumocephalus which was improved by conservative treatment. It is imperative to take into account the potential for tension pneumocephalus when a patient suffers from severe headache after sinus surgery.

CT observation of retromaxillary posterior ethmoid / 临床耳鼻咽喉头颈外科杂志

To investigate the morphologic characteristics of the retromaxillary posterior ethmoid.A total of 103 outpatients encountered in our hospital during March 2012 and December 2012,who completed paranasal sinus CT examination,were included in this study.Patients had no sinus trauma,surgery or tumor history.Their paranasal sinus CT scans were analyzed from scheduled axial and coronal plane.The incidence and imaging features of the retromaxillary posterior ethmoid were observed.The retromaxillary posterior ethmoid(RMPE)was the posterior ethmoid cell that expanded along the lamina papyracea toward the infraorbital region.RMPE was located behind the posterior wall of the maxillary sinus and under the orbital floor.The occurrence rate of the RMPE was 74.3%.The ethmomaxillary septum is the bony septum the between the maxillary sinus and posterior ethmoid.Anatomical confirmation of RMPE is based mainly on the presence of the ethmomaxillary septum.RMPE is located at the back of ethmomaxillary septum.The sagittal angulation of the ethmomaxillary septum ranged from 22 to 87 degrees,with an average of(50.34±12.10)degrees.The ethmomaxillary septum is important for anatomic recognition of the RMPE.Accurate identification of the RMPE before ESS can help improve the removal of the posterior ethmoid sinus.

Manejo endoscópico de osteoma etmoidal con extensión orbitaria: a propósito de un caso / Endoscopic manegement of frontoethmoidal osteoma: on case subject

El osteoma es el tumor más frecuente de los senos paranasales, habitualmente asintomático debido a su lento crecimiento, sin embargo, pueden desarrollarse síntomas dependiendo del tamaño, localización y extensión, con potencial compromiso de órbita y cerebro. La cirugía está indicada en casos sintomáticos pudiendo realizarse abordaje externo, endoscópico o combinado. Presentamos un caso de osteoma etmoidal con compromiso orbitario resuelto, manejado por medio de la cirugía endoscópica nasal, con apoyo de navegación.

The osteoma is the most common tumor of the paranasal sinuses, is usually asymptomatic because of their slow growth, however, may develop symptoms depending on the size, location and extent, with potential compromise of orbit and brain. Surgery is indicated in symptomatic cases, with external, endoscopic or combined approach. We present a case of ethmoidal osteoma with orbital involvement managed by endoscopic image guided surgery.

Melanomas nasosinusales / Sinonasal melanomas

Los melanomas mucosos representan 2 a 8% de todos los melanomas de cabeza y cuello. La mayoría se localizan en la cavidad nasal y senos paranasales. El objetivo de este estudio fue revisar la evolución de pacientes portadores de melanomas malignos nasosinusales (MMNS) en un hospital de atención terciaria. Material y Métodos: Serie de casos de 19 pacientes operados por MMNS en el Hospital "Carlos Andrade Marín" y algunos institutos privados de Quito. Todos con diagnóstico histológico confirmado. Resultados: Once varones con una edad promedio de 64 años. Sus síntomas más frecuentes fueron obstrucción nasal y epistaxis y la mayor parte de los tumores se localizaron en la fosa nasal. En 11 pacientes se encontró extensión extranasal. Doce pacientes estuvieron en estadios III-IV. Todos los pacientes recibieron tratamiento quirúrgico y siete de ellos radioterapia complementaria. Recurrencia local (11 eventos) ocurrió en 9 casos. Estos eventos fueron tratados con cirugía en ocho pacientes, que eventualmente recibieron radioterapia (RT) y quimioterapia (QT). 0cho de estos nueve pacientes fallecieron. La sobrevida global a 5 años fue del 46%. La mortalidad estuvo relacionada con la extensión de la enfermedad local y la presencia de metástasis. Todos los pacientes con estadio I están vivos. Discusión: La mayor parte de MMNS tiene mal pronóstico debido ­ principalmente- a enfermedad local inicialmente avanzada, recurrencia local y metástasis a distancia. La cirugía es el tratamiento de base seguido de RT.

Introduction: Head and neck mucosal melanoma account for 2 to 8% of head and neck melanomas, most of them arising in the nasal cavity or paranasal sinuses. The aim of this report was to review the follow up of patients with sinonasal malignant melanomas (SNMM), treated over a long period of time at a tertiary referral hospital. Methods: Case series of 19 patients surgically treated for SNMM at Social Security Hospital Carlos Andrade Marin and other private clinics from Quito Ecuador. All patients had histologically proven diagnosis; eleven men. Results: The mean age was 64 year-old. The most common symptoms were nasal obstruction and epistaxis. Most tumors were located at the nasal fossa. Extranasal extension occurred in 11 patients. Twelve tumor were at stages III-IV. All patients were surgically treated. Postoperative radiotherapy was given to 7 patients. Local recurrence (11 events) occurred in 9 cases. These events were treated with surgery in 8 patients, eventually associated to radiation therapy (RT) and chemotherapy (CT). Eight out of 9 patients died. Overall survival was 46%. Death was related to extension of the disease and distant metastases. All stage I tumor patients are still alive. Discussion: Most sinonasal melanomas have a poor prognosis, mainly attributed to initial advanced local disease, local recurrence and distant metastasis.

Drug-Eluting Sinus Stent for Chronic Rhinosinusitis / 대한이비인후과학회지

Chronic rhinosinusitis is one of the most common surgical disease in otorhinolaryngology field. Since the introduction of functional endoscopic sinus surgery in Korea in the early 1990s, the development of surgical equipments and techniques has led to a dramatic improvement in surgical outcomes. However, achieving good surgical outcomes with sinus surgery depends on postoperative care for avoiding local complications, such as scar formation, lateralization of middle turbinate, formation of synechia, stenosis of ostium, and mucosal polypoid change. Various medications and methods have been used to address these problems. Several types of drug-eluting stents have been used since the early 2000s to address these problems. There were a lot of researches on off-label local drug releasing system combining nasal packing material, topical medication, and ethmoid sinus was a main target lesion. The combination of steroids such as dexamethasone, triamcinolone and absorbable nasal packing material have been reported. Since 2010, products have been developed that are capable of sustained and constant drug outflow and are being used in clinical practice. There are still some problems to be solved, such as stent migration, not enough volume of drug in stents, and the high price of device, but if these problems are solved in the future, they may be more widely used in clinical practice.

A Case of Orbital Invasion of an Ameloblastoma

PURPOSE: To report a case of orbital invasion of ameloblastoma. CASE SUMMARY: A 69-year-old male patient was referred to the ophthalmologist from an otorhinolaryngology clinic due to mass invasion of the orbit on computed tomography. The patient had a history of ameloblastoma of the left maxilla, which had been diagnosed in 1988, and for which he had undergone left maxillectomy. He was transferred from a private hospital because of suspected tumor after frequent epistaxis at the left nasal cavity of about 1 year. The biopsy report confirmed that the mass was a recurrence of the ameloblastoma, and a 17.4 × 22.7 × 23.5-mm-sized mass that filled the left ethmoid sinus and invaded the nasal side of the orbit was found on paranasal sinus magnetic resonance imaging. There was no limitation of eye movement in any field of gaze in the left eye even though the patient reported diplopia. After maximum resection of the tumor using a debrider with endoscope, the size of the tumor was reduced and the symptom of diplopia was resolved. The patient will undergo continuous follow-up. CONCLUSIONS: Ameloblastoma is rare among orbital tumors originating from the paranasal sinus. We experienced a case of maxillary ameloblastoma involving the orbit. However, close monitoring should be administered to patients with such a tumor.

Treatment of Rhino-Orbito-Cerebral Aspergillosis with Combination of Amphotericin, Posaconazole and Amphotericin Irrigation: A Case Report

PURPOSE: To report a case of rhino-orbito-cerebral aspergillosis successfully treated with a combination of amphotericin B, posaconazole and amphotericin B irrigation. CASE SUMMARY: A 59-year-old male with hypertension, diabetes mellitus and hyperlipidemia was admitted to our neurology department for left facial paresthesia, pain and consulted to ophthalmology for left eyeball pain. His visual acuity was no light perception in the left eye, and fundus examination showed papilledema and a cherry-red spot. Left exophthalmos and complete ptosis with ophthalmoplegia were also observed. Orbital computed tomography revealed left maxillary and ethmoid sinusitis, and nasal endoscopic examination revealed a black eschar adjacent to the middle turbinate. Subsequent biopsy suggested mucormycosis. The patient was immediately treated with a combination of amphotericin B and posaconazole. In addition, left endoscopic sinus surgery was performed and aspergillosis was histopathologically confirmed. The patient underwent amphotericin B irrigation for 5 days after canula insertion up to orbital apex. The patient survived for 18 months and is still alive. CONCLUSIONS: A combination of amphotericin B, posaconazole and amphotericin B irrigation using the canula through the orbital apex may be helpful in treating patients with rhino-orbito-cerebral aspergillosis who refuse orbital exenteration.

A Case of Immunoglobulin G4-Related Sclerosing Disease of the Paranasal Sinus Mimicking Nasal Malignancy

Immunoglobulin G4 (IgG4)-related sclerosing disease (RSD) is a chronic inflammatory disorder characterized by elevated serum IgG4 levels as well as an abundant infiltration of IgG4-positive plasmacytes. Involvement of the paranasal sinus is very rare, so it is difficult to make an accurate diagnosis. Hence, various differential diagnoses, which typically include elevated serum IgG4 levels and the infiltration of IgG4-postive cells into tissues, need to be excluded, especially for malignant diseases and mimicking disorders. Systemic corticosteroids are generally effective at inducing IgG4-RSD remission. Recently, a 43-year-old woman presented with a mass originating from the ethmoid sinus, suggesting malignancy. The patient underwent biopsy of the lesion. The pathologic specimen revealed the magnitude of IgG4-positive plasma cell infiltration, which was consistent with IgG4-RSD. In addition, serum IgG4 levels were markedly increased. After glucocorticoid treatment, the serum IgG4 levels decreased and the symptoms improved. We present a rare case of IgG4-RSD with isolated involvement of the paranasal sinuses.