Ten-year experience with multidisciplinary diagnosis and treatment of odontogenic sinusitis.

BACKGROUND: Odontogenic sinusitis is an underdiagnosed entity and is one cause of failure of conventional treatments of sinusitis. Unfortunately, there is no consensus so far on the best management protocol. This retrospective study aimed to suggest a practical management protocol that can reduce misdiagnosis and improve treatment outcomes. METHODS: The study included 74 patients with confirmed odontogenic sinusitis who were diagnosed and treated over 10 years (2010-2019). The patient data were recorded and analysed. RESULTS: Dental pain was reported in only 31.1 per cent of patients. Fifty-six patients (75.7 per cent) had received dental treatment during the last year, but only 13 (23.1 per cent) reported it. Dental pathology was missed on initial computed tomography evaluation in 24 patients (32.4 per cent). Forty-one patients (55.4 per cent) were successfully treated by dental procedures and antibiotics. Fourteen patients needed functional endoscopic sinus surgery in addition to dental procedures. CONCLUSION: Successful management of odontogenic sinusitis requires good communication between rhinologists, radiologists and dentists. Dental treatment should be the logical first step in the treatment protocol, unless otherwise indicated.

The significance of atherosclerosis in hypertensive patients with epistaxis.

BACKGROUND: The relationship between hypertension and epistaxis is controversial and poorly understood. The present research investigated atherosclerosis as a potential risk factor in hypertensive patients with epistaxis. METHODS: A prospective study of 141 hypertensive patients with epistaxis was conducted. The laboratory tests included full blood count, lipid profile and coagulation profile. All patients underwent funduscopic examination of the eye and were classified in terms of four retinopathy grades. RESULTS: There were strong positive correlations between the number of nosebleeds and retinopathy grade and low-density lipoprotein cholesterol level. There were weak correlations between the number of nosebleeds and blood pressure readings and triglycerides levels. Patients with grade III retinopathy, suggesting atherosclerosis, suffered from more frequent nosebleeds than other patients. CONCLUSION: Atherosclerosis is one of the potential risk factors in hypertensive patients with epistaxis. This may have an impact on treatment choices.

Cluster of differentiation 8 T-cell population in the laryngeal mucosa of smokers with laryngeal cancer.

OBJECTIVE: To study the cluster of differentiation 8 population in the laryngeal mucosa of patients with laryngeal carcinoma. To our knowledge this is the first paper to address this issue. METHODS: The study group included 40 patients with known laryngeal cancer who were scheduled for laryngectomy. The control groups included 10 smokers and 10 non-smokers who were scheduled for microlaryngeal surgery. Specimens from the three groups were processed for histopathological and histochemical evaluation. RESULTS: In patients without cancer of the larynx, the number of cluster of differentiation 8 lymphocytes was greater in smokers than non-smokers. The number of cluster of differentiation 8 lymphocytes was greatest in smokers with laryngeal cancer, and the difference between this group and the two control groups was statistically significant. CONCLUSION: The study showed that smoking increased the number of cluster of differentiation 8 T-lymphocytes in the laryngeal mucosa. The increase was greatest in patients who had developed laryngeal cancer.

Effects of passive smoking on adult nasal respiratory mucosa.

OBJECTIVE: The present study aimed to investigate nasal mucosal changes in response to passive exposure to cigarette smoke. STUDY DESIGN: The study included 20 women aged 35-51 years who were scheduled for non-rhinological surgical procedures, and who had at least 10 years' prolonged passive exposure to household cigarette smoke. During surgery, two 1-mm3 biopsies of nasal mucosa were taken from the lower border of the inferior turbinate. Specimens were processed and examined with light and transmission electron microscopy. RESULTS: Examination of the nasal mucosa showed several histopathological changes. The severity of structural changes increased with duration of smoke exposure. No allergic or neoplastic changes were seen. CONCLUSION: Passive exposure to cigarette smoke has a deleterious effect on the nasal respiratory mucosa. Prolonged passive smoke exposure may also induce other, significant changes not detected in the present study.

Relationship between bacteriology of the adenoid core and middle meatus in children with sinusitis.

OBJECTIVE: To assess the correlation between bacterial pathogens in the adenoid core and the middle meatus, in children with hypertrophied adenoids and chronic or recurrent sinusitis. DESIGN: The study was conducted at Alexandria University Hospitals. We included 103 children aged four to 12 years who were scheduled for adenoidectomy and who had clinical and/or radiological evidence of chronic or recurrent sinusitis. Adenoid core specimens and middle meatal swabs were obtained from every patient and were sent for bacteriological evaluation using standard qualitative and quantitative microbiological techniques. The results were statistically analysed. RESULTS: The bacterial species isolated most frequently from the adenoid core were coagulase-negative staphylococci (40.8 per cent), Staphylococcus aureus (22.3 per cent), Streptococcus pneumoniae (18.4 per cent), Haemophilus influenzae (16.5 per cent) and group A streptococci (15.5 per cent). The bacterial species isolated most frequently from the middle meatus were coagulase-negative staphylococci (41.7 per cent), S aureus (32 per cent), S pneumoniae (28.1 per cent), H influenzae (21.6 per cent) and group A streptococci (19.4 per cent). The adenoid core and middle meatal cultures were both positive for at least one bacterial species in 63 cases, and were both negative in 25 cases. In six cases, a positive adenoid core culture was associated with a negative middle meatal culture. In five cases, a negative adenoid core culture was associated with a positive middle meatal culture (for one or more pathogenic species). Thus, adenoid core culture had a positive predictive value of 91.5 in forecasting the middle meatal culture result, and a negative predictive value of 84.3. CONCLUSION: Apart from its effect on nasal airway patency, adenoidal tissue may function as a bacterial reservoir initiating and maintaining sinus infection in children. These study findings support a potential role for adenoidectomy in the treatment of chronic or recurrent paediatric sinusitis.

Radiological observations on the olfactory fossa and ethmoid roof.

OBJECTIVE: To establish normative dimensions for the depth of the olfactory fossa, the length and angulation of the lateral lamella of the cribriform plate, and the height of the ethmoid roof, in adult males and females. DESIGN: The study assessed 300 high resolution, multislice computed tomography scans of the paranasal sinuses, which were evaluated using Merge Efilm software (version 2.0.0, build 37). RESULTS: According to the original Keros classification, the type II olfactory fossa was the commonest type in men (66.7 per cent), while the type I fossa was commonest in women (53 per cent). A difference of 3 mm or more between the depths of the right and left olfactory fossae was present in 11 per cent of men and 2 per cent of women. The lateral lamella of the cribriform plate was significantly shorter and less oblique in men than in women. The length of the lateral lamella was greater anteriorly than posteriorly in both sexes. There was a statistically significant difference between the angle of the lateral lamellae, comparing right and left sides. The ethmoid roof was lower in women than men. CONCLUSION: The observed differences between men and women and between the right and left sides are of surgical importance, and should alert surgeons to the need for thorough, systematic pre-operative evaluation of computed tomography scans.

The septal body revisited.

INTRODUCTION: The term septal body refers to a thickened area of the nasal septum which is located superior to the inferior turbinate and anterior to the middle turbinate. Despite its important role in changing nasal airflow resistance, it has received little attention. Clinically, a well developed septal body may be misdiagnosed as high septal deviation. AIM: The aim of the present study was to reassess the histological characteristics of the septal body mucosa and the morphometric differences between it and the adjacent septal mucosa. This information was then used to determine the exact location and surface area of the septal body. MATERIALS AND METHODS: The study was performed on 30 cadaveric specimens (60 sides). Serial numbered sections of the whole septal mucosa were stained with haematoxylin and eosin as well as periodic acid Schiff - Alcian blue. Morphometric analysis was performed to determine the histological differences between the septal body mucosa, the anterior septal mucosa and the inferior septal mucosa. The precise boundaries of the septal body area were then defined in a manner similar to the Mohs micrographic surgical technique. RESULTS: The histological characteristics of the septal body mucosa included thick (more than 60 microm), pseudostratified, ciliated respiratory epithelium with goblet cells, abundant seromucinous glands and many blood sinusoids. Morphometric analysis showed that the septal body mucosa had thicker epithelium and more glandular acini and blood sinusoids than the rest of the septal mucosa. Mapping of the septal body area showed that its anterior end was 2.2 +/- 0.3 cm (mean +/- standard deviation) behind the caudal edge of the septal cartilage, and its inferior border was 1.1 +/- 0.2 cm above the floor of the nose. The mean horizontal diameter of the septal body was 2.0 +/- 0.15 cm, and the mean vertical diameter was 1.5 +/- 0.11 cm. CONCLUSIONS: The present study determined the morphometric characteristics of the septal body as well as its location and surface area. The intimate relationship of the septal body to the internal nasal valve and the histological characteristics of its mucosa should stimulate research into its potential role in modifying nasal airflow pattern and resistance, and its role in changing the humidity and temperature of the inspiratory air stream.

Does laryngopharyngeal reflux affect healing and recovery after tonsillectomy?

INTRODUCTION: Laryngopharyngeal reflux is increasingly being implicated in several otolaryngological disorders. AIMS: To study a potential correlation between pre-operative laryngopharyngeal reflux and wound healing and recovery after tonsillectomy, based on subjective and objective findings. MATERIALS AND METHODS: A prospective, blinded study was undertaken, including 60 patients scheduled for tonsillectomy, divided into two equal groups: a study group (group A) with pre-operative laryngopharyngeal reflux documented using ambulatory 24-hour pH monitoring; and a control group (group B) without laryngopharyngeal reflux. RESULTS: Group A had significantly higher pain scores on the seventh and 14th post-operative days (p = 0.022 and p = 0.000, respectively) and took a significantly longer time to return to normal eating (p = 0.013), compared with group B. Group A also showed significantly slower healing on the seventh and 14th post-operative days, as estimated by assessing the grade of post-operative slough formation (p = 0.016 and p = 0.029, respectively). A significant correlation between the number of pharyngeal reflux episodes and the degree of post-operative slough was also found. CONCLUSIONS: Laryngopharyngeal reflux can significantly decrease wound healing following tonsillectomy. Therefore, pre-operative recognition and management of this condition is desirable in order to eliminate its negative post-operative effect.

Coblation tonsillectomy: a prospective, double-blind, randomised, clinical and histopathological comparison with dissection-ligation, monopolar electrocautery and laser tonsillectomies.

INTRODUCTION: Coblation tonsillectomy is a relatively recently introduced surgical technique which attempts to bridge the gap between 'hot' and 'cold' tonsillectomy methods. AIM: To compare coblation tonsillectomy with three commonly used surgical techniques: cold dissection-ligation, monopolar electrocautery and CO2 laser. MATERIALS AND METHODS: A prospective, randomised, double-blinded clinical trial was undertaken of 60 adult patients divided into three equal study groups. Patients in each group were randomly assigned to have one tonsil removed with coblation and the second with one of the other three tonsillectomy techniques. Ten randomly selected tonsils resected by each method were sent for histopathological evaluation. RESULTS: Coblation was significantly faster to perform than laser and produced significantly less intra-operative blood loss than both the dissection-ligation and laser techniques. Subjective visual analogue scale comparisons showed a non-significant pain score difference between coblation and dissection-ligation on most post-operative days. Coblation produced consistently highly significantly (p < 0.001) less pain, compared with electrocautery up to the 12th post-operative day and laser up to the 10th post-operative day. There was no significant difference in tonsillar fossa healing, comparing coblation to both dissection-ligation and laser techniques. Monopolar electrocautery produced significantly slower healing than coblation after 7 post-operative days, with no significant difference after 15 post-operative days. Histopathological evaluation showed that coblation inflicted significantly less thermal tissue injury than either electrocautery (p = 0.001) or laser (p = 0.003). CONCLUSIONS: In adult patients, coblation tonsillectomy offers some significant advantages in terms of post-operative pain and healing, compared with other tonsillectomy techniques.

Treatment of rhinitis medicamentosa with fluticasone propionate--an experimental study.

The efficacy of fluticasone propionate aqueous nasal spray (0.05% w/w) in the treatment of rhinitis medicamentosa has been studied in an animal model (guinea pig). Rhinitis medicamentosa was induced through the instillation of 0.05% naphthazoline nitrate (Privine) for 8 weeks. Fluticasone propionate nasal spray was then administered to the animals for 2 weeks. The spray successfully cleared the interstitial edema which is the pathologic hallmark of rhinitis medicamentosa. The study suggests that fluticasone propionate nasal spray can be beneficial in the treatment of patients with rhinitis medicamentosa.

Endoscopic carbon dioxide laser turbinoplasty.

In the present work we describe the management of hypertrophied inferior turbinates using CO(2) laser in the UniPulse mode. The laser beam is delivered through the nasal probe delivery system, and the procedure is performed using the 0 degrees endoscope. The UniPulse mode allowed fine-tuned, char-free tissue ablation, and the nasal probes allowed delivery of laser energy to the posterior parts of the inferior turbinates. The procedure was performed on 149 patients. The one-year post-operative follow-up period revealed good functional results in 131 patients (88 per cent). The minimal nasal cross sectional area increased significantly from 0.52 cm(2) to 0.81 cm(2). The average decongestive effect, on the other hand, decreased from 0.26 cm(2) to 0.07 cm(2) indicating significant laser-induced fibrosis. The operation can be performed as an out-patient procedure with little or no morbidity.

Endoscopic anatomy of the sphenoid sinus.

The anatomy of the sphenoid sinus, as it relates to endoscopic sinus surgery, was studied in 93 cadaver heads (186 sphenoid sinuses) using endoscopic dissections as well as sagittal sections. The relationship of the sphenoid sinuses to the carotid artery, optic nerve, floor of sella turcica, as well as other important structures, were verified and discussed. The recesses of the sinus as well as its ostium and accessory septa and crests were described and their clinical importance was discussed. Pertinent measurements were included wherever appropriate.

Laser surgery for allergic rhinitis: the effect on seromucinous glands.

Ten patients with perennial allergic rhinitis were subjected to CO2 laser turbinectomy. Tiny (1 mm3) biopsy specimens were taken at the time of surgery and 1 month thereafter. The biopsy specimens were processed for transmission electron microscopy. Also, the activity of succinic dehydrogenase and cholinesterase enzymes was measured. The study showed that laser turbinectomy was followed by reduction in the number and activity of the glandular acini in the laser-treated areas. This reduction is ascribed to the local destructive effect of laser energy on the glandular acini and on the surrounding cholinergic nerve fibers. The enzymatic activity of the cholinergic nerve fibers themselves, however, did not diminish, indicating that laser surgery has no inhibitory effect on the local allergic reaction.

Radiofrequency bipolar submucosal diathermy of the inferior turbinates.

Fifty nonatopic patients with chronic hypertrophic rhinitis and suffering from chronic nasal obstruction due to hypertrophied inferior turbinates were subjected to bipolar submucosal diathermy using a radio frequency unit and a bipolar turbinate probe. One year postoperatively, 76% of patients showed significant improvement of their nasal breathing and another 16% reported partial improvement. The minimal cross sectional has also significantly increased from 0.58 +/- 0.05 cm2 to 0.72 +/- 0.04 cm2 and the decongestive effect was statistically significant. Electron microscopic examination of the nasal mucosa at the end of the follow up period revealed intact healthy epithelium as well as intense fibrosis of the underlying stroma. The results of the work showed that bipolar submucosal diathermy is a safe, effective outpatient procedure that does not require nasal packing or expensive instrumentation. The procedure can be repeated, if necessary, according to the patient's needs.

The effect of endoscopic sinus surgery on mucociliary clearance in patients with chronic sinusitis.

The saccharin test was used to measure mucociliary clearance in 50 patients with symptoms of chronic sinusitis. Samples of the nasal mucosa were also examined under transmission electron microscopy before and after functional endoscopic sinus surgery (FESS). Before surgery, the mean saccharin clearance (ST) was 37.0 +/- 15.7 min, with nasal mucosa exhibiting ciliary loss as well as other ultrastructural changes. Three months after surgery, the mean ST had improved to 20.3 +/- 7.5 min and significant regeneration of cilia was observed. It was therefore concluded that FESS had successfully corrected mucociliary dysfunction in these patients.

Carbon dioxide laser turbinectomy. An electron microscopic study.

Ten patients with chronic non-allergic rhinitis and presenting mainly with nasal obstruction due to hypertrophied inferior turbinates were subjected to laser turbinectomy using CO2. Tiny biopsies were taken, at the time of surgery as well as one month later, and were processed for transmission electron microscopy. The ultrastructural observations included: early epithelial loss which was followed by prompt regeneration of healthy epithelium, decreased number and activity of the seromucinous glands, fibrosis of the connective tissue stroma, as well as diminished number and congestion of the cavernous blood spaces. These observations were discussed in view of the excellent clinical response of the patients.

Topical levocabastine for the treatment of perennial allergic rhinitis.

The ultrastructure of the nasal mucosa following the use of intranasal levocabastine was studied in 20 patients suffering from perennial allergic rhinitis. The patients received twice daily 0.05 per cent levocabastine spray with a treatment duration of four weeks. At the end of the treatment period regression of the allergic process was evidenced by progressive reappearance of normal cilia and microvilli on the columnar cells, decrease of intercellular oedema and cytoplasmic vacuoles, increased number of mucous acinar cells, gradual decrease of vascular congestion, as well as diminished oedema fluid formation. The drug, however, had no effect on mast cell degranulation nor on eosinophilic infiltration. Normalization of the ultrastructural features correlated well with clinical improvement. Considering the results of the present study, levocabastine nasal spray appears to be an effective treatment for perennial allergic rhinitis and can be used with, or as an alternative to, other anti-allergic medications.

Endoscopic control of posterior epistaxis.

Control of bleeding vessels by suction cautery under endoscopic vision was used on 38 patients suffering from posterior epistaxis. Twelve patients also required the insertion of nasal tampons at the end of the cautery procedure. Eight patients, six of them hypertensive, had recurrent epistaxis post-operatively. Five patients needed further cautery in order to control the bleeding. Three patients required temporary balloon tamponade, and a single patient had internal maxillary ligation. Temporary palatal numbness in three patients was the only post-operative complication. Otherwise, the technique has the potential advantages of simplicity, safety, effectiveness and simplified post-operative care.

Obstruction of the nasal valve.

Obstruction of the nasal valve is an important cause of chronic nasal obstruction in adults. In a series of 500 patients, obstruction at the level of the nasal valve was diagnosed in 65 of them (13 per cent). The obstruction was unilateral in 57 patients (88 per cent). Forty-seven patients (72 per cent) had history of previous nasal surgery of accidental trauma. Causes of obstruction of the nasal valve included high septal deviations, a weak or deformed upper lateral cartilage, adhesions, and alar collapse. All patients underwent corrective nasal surgery and the surgical procedures were tailored according to the existing pathology. Post-operatively, the mean nasal patency score increased from 2.9 to 8.6, the mean nasal airflow increased from 579.5 to 727 cm/sec (at 150 Pa), and the mean nasal resistance decreased from 0.31 to 0.23 Pa/cm3 sec-1.

Pathology of the eustachian tube in otitis media: an electron microscopic study.

The ultrastructure of the mucosa of the eustachian tube was studied in four temporal bones showing tympanosclerosis, cholesteatoma, otitic meningitis and a grafted tympanic membrane (tympanoplasty). The mucosa of tube was abnormal in the four cases confirming the relationship between the state of the eustachian tube and the inflammatory process in the middle ear. The observed abnormalities included: ciliary loss, abnormal ciliary morphology and motility, oedema of the microvilli, hyperplasia of the goblet cells and the seromucinous acini, desquamation of the non-ciliated cells and appearance of mast cells in the lamina propria of the tube. Ciliary changes were the most frequent abnormalities and the morphological changes, in general, were fewest in the case of healed tympanoplasty. The pathophysiology of the morphological changes was discussed and correlated with the disease in the middle ear.